Oxford

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Multi-vessel disease Le Mans implications
Oxford
The John Radcliffe Hospital
Dr Adrian Banning
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Multi-vessel diseaseLe Mans - implications ?

• Lemans trial J Am Coll Cardiol 2008
• Small randomised trial of CABG vs PCI for
  patients with left main disease
• Syntax Lemans
• Subset of the Syntax trial
• patients with left main disease
• follow up angios at 15 months (both surgical and
  PCI)
• To be reported at PCR 09

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Why is the Left Main important?
It supplies at least 2/3 of the blood to the
heart!!!
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Why is the left main special?

• Large vessel
• Prone to calcification
• Large volume of plaque required to cause stenosis
• Intubated by the diagnostic catheter ostium?
• By definition terminates in a bifurcation at
  least
• Untreated LMS stenosis gt 20 mortality at 1yr

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Results of initial intervention on the LMS- the
early years

• 1980s Hartzler using POBA
• 10 procedural mortality in hospital
• 64 3yr mortality
• Early 1993-8 ULTIMA
• 279 pts unprotected LMS
• 14 procedural mortality in hospital
• 25 mortality at one year
• NB if 46 inoperable are excluded
• 97 1yr survival in these low risk pts

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Can we predict risk when stenting the LMS?
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Stent the LMS with BMS safe, but high rate of
MACE due to restenosis
Am J Cardiol. 20039112-6.
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A Randomized Comparison of Paclitaxel-ElutingSten
ts Versus Bare-Metal Stents for Treatmentof
Unprotected Left Main Coronary Artery Stenosis

• 103 patients
• BMS (n 50) or PES (n 53).
• All IVUS guidance and Cutting balloon
  pretreatment x 3 to cover entire lesion
• Ostium and body were treated with a single stent
• Single stent 49/50 and 52/53
• Final kissing balloon dilation was performed
  only in cases with
• suboptimal result at the LCX ostium (6 and 19)
• Follow-up 6 months angio and IVUS
• No late stent thrombosis in either group

Erglis et al JACC 2007
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A Randomized Comparison of Paclitaxel-ElutingSten
ts Versus Bare-Metal Stents for Treatmentof
Unprotected Left Main Coronary Artery Stenosis
Erglis et al JACC 2007
10
A Randomized Comparison of Paclitaxel-ElutingSten
ts Versus Bare-Metal Stents for Treatmentof
Unprotected Left Main Coronary Artery Stenosis
Erglis et al JACC 2007
11
A Randomized Comparison of Paclitaxel-ElutingSten
ts Versus Bare-Metal Stents for Treatmentof
Unprotected Left Main Coronary Artery Stenosis
Erglis et al JACC 2007
12
A Randomized Comparison of Paclitaxel-ElutingSten
ts Versus Bare-Metal Stents for Treatmentof
Unprotected Left Main Coronary Artery Stenosis
Erglis et al JACC 2007
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Location matters
Ostium
Distal- bifurcation
Shaft
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What makes the left main special?

• Anatomy matters
• Ostial Needs 1 stent
• Body Needs 1 stent
• Bifurcation Usually gt1 stent, 2 wires, gt6F

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Preliminary DES in LMS disease?
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Long-Term Outcome After DES in Nonbifurcation
Lesions that involve Unprotected LMS

• Population 147 pts
• elective (only) consecutive pts SES or PES in 5
  centers
• - stenosis in the ostium and/or the mid-shaft of
  an unprotected LMCA
• PCI instead of surgery was considered either
• (1) suitable anatomy for stenting and preference
  patient and physician
• (2) suitable anatomy for stenting and EuroSCORE
  6 and/or Parsonnet score 13 and/or prior bypass
  surgery with failure of all conduits (n2).

Chieffo et al Circulation 2007
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Favorable Long-Term Outcome After Drug-Eluting
Stent Implantation in Nonbifurcation Lesions That
Involve Unprotected Left Main Coronary

• Medications
• IIb/IIIa inhibitors at the discretion of the
  operator.
• Dual antiplatelet therapy for at least 6 months
  after. All patients were advised to maintain
  lifelong use of aspirin (100 mg/d).
• Clinical follow-up at 1, 6, 12, and 24 months.
• Patients eligible for longer clinical follow-up
  were contacted at 36 and 48 months.
• Angio follow-up 4 and 9 months or earlier if
  neccesary
• Total follow up mean 886 days

Chieffo et al Circulation 2007
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Favorable Long-Term Outcome After Drug-Eluting
Stent Implantation in Nonbifurcation Lesions That
Involve Unprotected Left Main Coronary
Chieffo et al Circulation 2007
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Favorable Long-Term Outcome After Drug-Eluting
Stent Implantation in Nonbifurcation Lesions That
Involve Unprotected Left Main Coronary
Chieffo et al Circulation 2007
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Favorable Long-Term Outcome After Drug-Eluting
Stent Implantation in Nonbifurcation Lesions That
Involve Unprotected Left Main Coronary
Chieffo et al Circulation 2007
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Favorable Long-Term Outcome After Drug-Eluting
Stent Implantation in Nonbifurcation Lesions That
Involve Unprotected Left Main Coronary
Chieffo et al Circulation 2007
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Favorable Long-Term Outcome After Drug-Eluting
Stent Implantation in Nonbifurcation Lesions That
Involve Unprotected Left Main Coronary
No proven late stent thrombosis 4 unexpected
deaths
Chieffo et al Circulation 2007
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Favorable Long-Term Outcome After Drug-Eluting
Stent Implantation in Nonbifurcation Lesions That
Involve Unprotected Left Main Coronary
Chieffo et al Circulation 2007
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What about late stent thrombosis in LMS disease?

• Specific worries
• Late thrombosis for all DES gtBMS
• Late thrombosis higher off label
• Higher risk of incomplete expansion?
• Left main occlusion will be fatal
• Reassurances
• Big vessel

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Late and very late stent thrombosis following
DES in ULM. Chieffo et al, EHJ Sept 2008.

• Multicentre registry of 731 pts with
• Elective DES stenting of ULM disease.
• Definite ST
• 4 pts (0.5). 3 early (30d), 1 late ( 1 yr).
  No VLST.
• Probable ST 3 pts. All early (30d)
• Definite or probable ST 7 / 731 0.95
• All were on dual AP Rx.
• Possible ST
• (8 late, 12 very late) in 20 (2.7) pts.

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Late and very late stent thrombosis following
DES in ULM. Chieffo et al, EHJ Sept 2008.

• Outcomes after 29.513.7 months follow up
• Death 6.2 (n45).
• Cardiac death 4.2 (n31)
• TVR 12.9 (n95)
• TLR 10.9 (n76)
• Restenosis rate 14.1 on angiographic follow-up
  of 548 pts.
• (NB 76 of lesions involved the distal LM.)
• Predictors of ST at logistic analysis
• Euroscore
• LVEF
• Consistent with general PCI population.
• No unique ST predictor among ULM pts identified
  in this analysis.
• Conclusion Elective DES stenting of ULM is safe
  - low rates of ST.

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358 consecutive patients 7 centres All DES
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Elective Urgent MACE free 74 68 Mortality 6
21 Reinfarction 8 10 TLR 7
3 TVR 16 7
Delft J Am Coll Cardiol 2008 51 2212-9
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• So can stents replace surgeryin left main
  disease?

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Unprotected left main stenting vs CABGSeung et
al, NEJM April 2008.

• Long term follow up of 1102 patients stenting for
  ULM disease,
• vs propensity-matched cohort of CABG patients
• No significant difference in the risk of death
  and the composite outcome of death, Q-wave MI, or
  stroke between the two groups.
• TVR higher in the stents group, even with DES.

Seung KB et al. N Engl J Med 20083581781-1792
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Study of unprotected LEft MAiN Stenting versus
bypass surgery J Am Coll Cardiol 2008 51 538-45
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Lemans study design
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PCI technique Direct stenting preferred if not
poss predil with 2 or 2.5 Bifurcation technique
Initial stent to LAD then Cullotte or Prov T if
necessary No crush stenting IVUS advised DES if
diameter lt 3.8mm (35) LeMans study 2008
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Improved EF with PCIETT similar by 12 months
more angina PCI initially
Lemans trial 2008
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LeMans survival
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SYNTAX Eligible Patients
De novo disease

• Limited Exclusion Criteria
• Previous interventions
• Acute MI with CPKgt2x
• Concomitant cardiac surgery

Left Main Disease (isolated, 1, 2 or 3 vessels)
3 Vessel Disease (revasc all 3 vascular
territories)
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Syntax Lemans (reports PCR 09)

• All left main pts in the randomised Syntax n710
• Follow up angio at 15 months
• Asses late angio outcomes with clinical outcomes
• Asses utility of angio follow up
• Stats
• Surgery occlusion rate rate 5-12
• 100 surgery pts 95 confidence interval
  (/-0.043) if occlusion is 5 or (/-0.043) if
  occlusion is 12
• PCI Expected Patency rate 74-97
• 100 PCI pts 95 confidence interval (/-0.078) if
  patency is 80
• Expected attrition 30

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12 Month LM Subgroup MACCE Rates
Patients ()
All LMN705
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12 Month Subgroup MACCE Rates
Patients ()
3VD (All) N1095
LM3VD N258
All LMN705
LM1VDN138
LM isolatedN91
LM2VDN218
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So why is the left main special?

• The left main is unforgiving during PCI
• Because large volumes of myocardium are at risk
• Large volumes of plaque may move
• Calcification is restrictive to stent expansion
• loss of branches will have immediate and
  profound haemodynamic consequences
• The left main is unforgiving in the long term
• All ostial disease has a very high restenosis
  rate (particularly if the stent is incompletely
  expanded).

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What do we know about left main PCI?

• Procedural risk fallen from 10-20 to lt1
• (in all but shock cases)
• Ostial and shaft disease is different to terminal
  disease of the main
• Left main PCI should be definitely considered in
  all emergency cases and many urgent cases

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What do we know about left main PCI in 2008?

• DES are almost certainly better than BMS
• Risks of treating left main disease with PCI or
  surgery are probably the same
• Long term results of DES in elective ostial and
  shaft disease are very encouraging
• Those cases treatable with one properly expanded
  stent

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What do we know about left main PCI in 2008?

• However
• How do we treat distal bifurcation disease best?
• Perhaps the cullotte? Not the crush for me
• LMS 2VD / 3VD
• surgery still has lower rates of TVR particularly
  in diabetics

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Isolated left main stenting in 2008