Myocardial Revascularization East vs West “Lecture in Memory of Prof. Zhu Guoying”

Prof. Yean L. Lim AM 8th SWCC, Chengdu 5 July 2014

Coronary Revascularization Coronary Revascularization East versus WestEast versus West

PCI versus CABG : differences between the East and West

Alternative strategy to achieve Complete Revascularization in stable MVD patients

Evidence needed for daily practice and potential contribution to CAD therapy from the East

Decline in Revasc Rates in Mass. USADecline in Revasc Rates in Mass. USAYeh RW et al, ACC 2014Yeh RW et al, ACC 2014

Between April 2003 to Sep 2012; rate per 100k pop.Between April 2003 to Sep 2012; rate per 100k pop.

20032003 20122012

All RevascularizationAll Revascularization 423423 258258

MortalityMortality 2.4% 2.4% 1.9%1.9%

PCIPCI 317317 199199

Elective PCIElective PCI 200200 101101

STEMI PCISTEMI PCI 117117 98 98

30d Mortality30d Mortality 2.0% 2.0% 2.0%2.0%

CABGCABG 106106 59 59

30d Mortality30d Mortality 3.4% 3.4% 1.6%1.6%

質与量並增

Differences in Coronary Revascularization Differences in Coronary Revascularization between the East and the Westbetween the East and the West

Comprehensive PCI services without on-site Comprehensive PCI services without on-site CABG surgical services in most Eastern CABG surgical services in most Eastern hospitalshospitals

Ratio of PCI to CABG, when CABG, ranging Ratio of PCI to CABG, when CABG, ranging from 3:1 to zero CABG in Eastern hospitals from 3:1 to zero CABG in Eastern hospitals with CABG surgerywith CABG surgery

Preference for PCI in the East due to socio-Preference for PCI in the East due to socio-economic and cultural factorseconomic and cultural factors

Difference in Procedural risks between Difference in Procedural risks between PCI & CABG RevascularizationPCI & CABG Revascularization

Risk of PCI is related more to Risk of PCI is related more to Lesion Lesion factors (complexity)factors (complexity)

Risk of CABG is related to Risk of CABG is related to PatientPatient FactorsFactors (co-morbidities)(co-morbidities)

Risk of PCI is related to Risk of PCI is related to singlesingle operator operator’’s s skill level skill level

Overall risk of CABG is dependent on the Overall risk of CABG is dependent on the entire treating entire treating teamteam (surgeon, anesthetist (surgeon, anesthetist & ICU staff)& ICU staff)

中國冠脤介入死亡率

Higher Death & MI rates for DES compared to Higher Death & MI rates for DES compared to CABG for MVD (Fu Wai Hospital)CABG for MVD (Fu Wai Hospital)

Between 1/4/2003-31/12/2005Between 1/4/2003-31/12/2005 3720 consecutive pts with MVD, CABG (1886), DES 3720 consecutive pts with MVD, CABG (1886), DES

(1834)(1834) Higher Death rate in DES (HR 1.62, 95% 1.07-2.47)Higher Death rate in DES (HR 1.62, 95% 1.07-2.47) Higher MI rate in DES (HR 1.65; 95% 1.15-2.44)Higher MI rate in DES (HR 1.65; 95% 1.15-2.44) Similar Stroke rate in both (HR 0.92; 95% 0.69-1.51)Similar Stroke rate in both (HR 0.92; 95% 0.69-1.51)

Li Y et al, Circulation 2009; 119:2040-50

2008; 7607 cardiac surgery performed at 2008; 7607 cardiac surgery performed at Fu Wai Hospital, Beijing (Congenital Fu Wai Hospital, Beijing (Congenital 48.3%;CABG 23.3% >50% off-pump; VHD 48.3%;CABG 23.3% >50% off-pump; VHD 19.5%,others 8.9%, 38 transplants)19.5%,others 8.9%, 38 transplants)Total Mortality 1.2%Total Mortality 1.2%

北京阜外醫院心外科縂數及死亡率

Hu S et al, Circ Cardiovasc Qual Outcomes 2012: 5(2):214-21Hu S et al, Circ Cardiovasc Qual Outcomes 2012: 5(2):214-21

43 hospitals, 8739pts, Age 62.2, 78% M) 1/1/2007-31/12/2008 Risk standardized in-hosp. all-cause mortality (RSMR) Risk standardized major complication rate (RSMCR) Overall RSMR 2.2%; RSMCR 6.6% RSMR & RSMCR Eastern region: 1.6% & 5.8% RSMR & RSMCR Crntral region: 2.5 & 7.7%

中國心外科血運重建死亡率 (2008)

東西方冠脈介入血運重選擇與策略的差異CV Interventions Intercontinental Crossfire EuroPCR 2011

Courtesy of Prof. Yang YuejinLive Transmission from Fu Wai Hospital Beijing to EuroPCR 2011

Complete Coronary Revascularization by PCI(Eastern Practice with limited CABG Expertise)

Final ResultFinal Result

Live Transmission from Fu Wai Hospital Beijing, China to EuroPCR 2011

““Co-evolutionCo-evolution”” rather than rather than Crossfire between East & WestCrossfire between East & West

“Mr. Kissinger insists thatthe common interests the two (east & west) share should make possible a “co-evolution”……creatinga Pacific Community, comparable to the Atlantic Community.…...All Asian nations would then participate in a system perceived as a joint endeavor rather than a contest of rival (east & west) blocs.

Maxwell Frankel, Herald Tribune 14-15 May 2001Except from Book review “On China by Henry Kissinger”

““Co-EvolutionCo-Evolution”” between East & West PCIs between East & West PCIs

SYNERGY(Hexagon) Area

Strengths of the West1 Good Clinical & Surgical Expertise2 Great Educational Programs (TCT-AP, CIT-TCT, EuroPCR- AP)3 Good GCP & Database4 Good GMP

Strengths in the East1 Bench research2 Large patient pool for clinical trials3 Better skills in complex & high risk intervention 4 Cheaper cost

Synergy of PCI between West & East:

Coronary Revascularization Coronary Revascularization East versus WestEast versus West

PCI versus CABG : differences between the East and West

Alternative strategy to achieve Complete Revascularization in stable MVD patients

Evidence needed for daily practice and potential contribution to CAD therapy from the East

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 Centrereduces both CABG and PCI ratesreduces both CABG and PCI rates

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

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

Long-term Outcome of CR vs IR by DES-PCI in Patients with MVD

Fu Wai Hosp, Apr 2004-Nov 2010; 7065 MVD ptsFu Wai Hosp, Apr 2004-Nov 2010; 7065 MVD pts, , 1188 CR (AngioCR =Complete Revasc. PCI of all 1188 CR (AngioCR =Complete Revasc. PCI of all

lesions in major CA + SB>2.5mm.; Prox. CR= PCI of all lesions in major CA + SB>2.5mm.; Prox. CR= PCI of all prox. Lesions in maj. CA)prox. Lesions in maj. CA)

2053 IR (Angio. Or Prox. IR Not all lesions in MV or SB 2053 IR (Angio. Or Prox. IR Not all lesions in MV or SB treated by PCI)treated by PCI)

Results: Angio. CR/IR Results: Angio. CR/IR HR 2.56 (95% 1.03-6.41)HR 2.56 (95% 1.03-6.41)

Prox. CR/IR Prox. CR/IR HR 1.72 (95% 0.93-3.17)HR 1.72 (95% 0.93-3.17)

>2VD subset: Angio CR/IR HR 4.25 (95% 1.5-12.1)>2VD subset: Angio CR/IR HR 4.25 (95% 1.5-12.1)

Prox. CR/IR HR 3.02 (95% 1.4-5.2)Prox. CR/IR HR 3.02 (95% 1.4-5.2) Conclusion: Pts with MVD treated by PCI, Cardiac death Conclusion: Pts with MVD treated by PCI, Cardiac death

rate at 3 yr better in Complete compared to incomplete rate at 3 yr better in Complete compared to incomplete revasc. revasc.

P=0.294P<0.001

P<0.001P<0.001

Coronary Revascularization Coronary Revascularization East versus WestEast versus West

PCI versus CABG : differences between the East and West

Alternative strategy to achieve Complete Revascularization in stable MVD patients

Evidence needed for daily practice and potential contribution to CAD therapy from the East

2014 Medical Decision Making for MVD Revascularization

Single case (SELF) study

Evidence-based Practice

RCTs>Registry Database>Observational

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

patient, what would you have done? )

PCI for all CAD ( Stable and ACS ) with MVD PCI for all CAD ( Stable and ACS ) with MVD Personal Belief & PracticePersonal Belief & Practice: Staged PCI to achieve CR: Staged PCI to achieve CR

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

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.

Complete Coronary Revascularization in Complete Coronary Revascularization in East & West- Current StatusEast & West- Current Status

Higher TVR rate for PCI is well accepted by patientsHigher TVR rate for PCI is well accepted by patients Success & in-hospital mortality rate of CABG for all Success & in-hospital mortality rate of CABG for all

comers is better in the Westcomers is better in the West Currently complete coronary revascularization is Currently complete coronary revascularization is

more likely to be achieved by PCI in the East than more likely to be achieved by PCI in the East than the Westthe West

However, long-term non-inferiority results of PCI However, long-term non-inferiority results of PCI revascularization practice in the East is lackingrevascularization practice in the East is lacking

Is eventual complete multiple staged PCI non-Is eventual complete multiple staged PCI non-inferior to single CABG surgery ?inferior to single CABG surgery ?

Personal observations of variation in Complete Coronary Revascularization :

East & West

PCI: Similar success and complication rate in both East & West (Mortality 0.26%, Europe 0.8%)

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

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

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

RCT needed to compare E vs W CR

ConclusionsConclusions PCI rates are decreasing in the west (US 0.5-PCI rates are decreasing in the west (US 0.5-

1.3/1000) but increasing in the east (China 1.3/1000) but increasing in the east (China 0.03/1000)0.03/1000)

Complete coronary revascularized is being Complete coronary revascularized is being achieved by PCI more in the east than the west. achieved by PCI more in the east than the west. However, evidence for this practice is lackingHowever, evidence for this practice is lacking

Functional staged incomplete PCI revascularization Functional staged incomplete PCI revascularization to treat stable MVD patients is reasonable, again to treat stable MVD patients is reasonable, again good evidence is needed for such practice in both good evidence is needed for such practice in both east and west east and west

謝謝朱國英教授謝謝朱國英教授 ,,我們的良師益友我們的良師益友 !!