MY PERSPECTIVE OF CABG Reduction of ischemic burden should be the end point of our treatment

1. CABG VS PCI
MY PERSPECTIVE
I
DR.NILESHTAWADE
JASLOK HOSPITAL AND RESEARCH CENTRE, MUMBAI

2. CABG VS PCI
PCI CABG

3. CABG VS PCI
Both CABG and PCI are safe and established treatment for
patients with mutivessel coronary artery disease (MVD)
BUT Before performing a CABG or PCI answers to
following questions to be sorted out
• Is it going to prolong the life (Mortality Benefit )?
• Is it going to improve quality of life in terms of (Symptomatic Benefit )
• Angina
• Repeat MI
• Rehospitalization / Reprocedure
• Is it in reasonable costs?

4. Concept of “FUNCTIONAL
SYNTAX SCORE”

9. The long term effects of PCI in
mutivessel disease will be best
studied by the concept of
“ Functional Angioplasty ”

10. What Is Concept Of Functional Angioplasty ?

12. BUT HOW TO EVALUATE “CLINICAL
ISCHEMIA” IN CATH LAB

13. WHY FFR ?
1. Accurate Diagnosis First !
2. Angiographic Assessment is Not Always Enough.
1. There are Many Visual Functional Mismatches.
2. FFR is Crucial for Intermediate LM Ostial
3. and Shaft Lesions.
3. Avoid Unnecessary Procedure is the Most Important
4. Factor to Reduce Unfavorable Outcomes.

14. More Stents Means Just More MACCE !
SYNTAX: RCT (n=4.6)
Dejan et al. (n=3.3)
Li Y et al.
(n=2.7) X:Registry (n=3.1)
AUTAX (n=3.2)
FAME, Angio guided, (n=2.7)
PRECOMBAT
(n=2.7)
FAME
FFR guided
(n=1.9)
ASAN Multivessel Registry (n=2.8)
Stent Number
1YearRepeat
Revascularization,%

15. FFR IS COST EFFECTIVE AND IMPROVES
OUTCOMES

16. FFR vs. Angio-Guided PCI
(Meta-analysis n=9,301)
Outcomes Relative Risk
Reduction
P value
TVR 42% <0.001
DEATH 53% < 0.0010
MI 30% 0 .06
MACE 29% <0.001
Park SJ, Ahn JM et al. Unpublished data, 2013

17. SUMMARY

20. Reasonable incomplete revascularization may be clinically indicated in certain situations.
Dauerman H L Circulation. 2011;123:2337-2340
Copyright © American Heart Association, Inc. All rights reserved.

22. CRITERIA FO OPTIMAL STENT DEPLOYMENT

23. Post stenting

24. Effective
evaluation of
1.Plaque
composition
2.Stent
expansion
3.Stent
apposition
4.Edge

26. EXCEL- LM TRIAL
 Evaluation of XIENCE PRIME™ Everolimus Eluting Stent System
(EECSS) or XIENCEV® EECSSVersus Coronary Artery Bypass Surgery
for Effectiveness of Left Main Revascularization (EXCEL)ClinicalTrial.
 It will clarify the role of second-generation drug-eluting stents for LM
disease.
 Which will include 2,600 randomized patients and compare surgery to
stenting
 Study started in SEP 2010, EstimatedCompletion of primary date
APRIL 2017.

27. UNFAVOURABLE ASPECTS OF CABG
Major invasive procedure
Considerable pain and morbidity
Saphenous vein grafts (SVGs) that are much less effective at late follow-up compared with the LIMA
Comparing CABG with DES, did not find differences in procedural mortality
CABG patients sustained more stroke, serious arrhythmia, need for permanent pacemaker, renal failure, repeat
surgery for bleeding and cardiac tamponade.

28. Deterioration of Native Circulation after CABG

29. Deterioration of Native Circulation

30. UNFAVOURABLE ASPECTS OF CABG
 RIMA, SVG and Radial grafts
have a <50% patency rate at
5 years
 Radial artery grafts 
worst patency rate of all
graft types

31. Post Operative Day 1
POST CABG
POST PTCA ---READY TO
GO HOME

32. CONCLUSIONS
 Reduction of ischemic burden should be the end point of
our treatment
 We should avoid to be guided by angiographic
impressions
 If we have to equate PCI outcome to SURGICAL
outcome , reduction in TLR must be achieved . This
would mean good pharmacological approach, robust
technique and COST effectiveness