Percutaneous or Surgical Revascularization for Multivessel Coronary Artery Disease?,Verghese Mathew, MD, FACC Consultant, Division of Cardiovascular Diseases and Department of Radiology Professor of Medicine, Mayo Clinic College of Medicine,Revascularization Strategies,How do we decide?,Anatomy Clinical Patientpresentation preference,Risk vs. Benefit,Invasive Therapies,Low Risk Patient,High Risk Patient,Some acute risk,Less long-term risk reduction,Greater acute risk,Greater long-term risk reduction,12-Year Survival in Patients with CAD,50 35-49 35,Emond M et al: Circ 90:2645, 1994,23,467 Medically-Treated Patients in CASS Registry,LVEF,CP1203018-2,12-Year Survival in Patients with CAD,No CAD 1 vessel 2 vessel 3 vessel,Emond M et al: Circ 90:2645, 1994,23,467 Medically-Treated Patients in CASS Registry,CP1203018-1,Clinical Presentation,Age Acute ischemic syndrome versus chronic stable angina Prior cardiac history (MI, CABG, intervention) Co-morbid conditions (diabetes, cerebrovascular disease, renal disease, lung disease) Functional impairment Ischemic burden,Extension of Survival with CABG vs Medical Therapy After 10 Years,CP1203018-14,Extension of survival (mo),Yusuf S et al: Lancet 344:563, 1994,Overall,Vessel disease 1/2 vessels 3 vessels Left main,LV function Normal Abnormal,Exercise test Normal Abnormal,Angina Class 0, I, II Class III, IV,Low Moderate High,Low Moderate High,VA risk score,Stepwise risk score,CABG vs Stenting for MVD Meta-Analysis of ARTS, ERACI-II, MASS-II and SOS,Circ 118, 2008,Days,Event-Free Survival Analysis of Death,1,518 1,472 1,456 1,440 1,406 1,3471,533 1,479 1,457 1,439 1,412 1,349,Overall survival (%),P=0.78,Days,Repeat Revascularization,1,518 1,204 772 740 707 6651,533 1,428 927 911 882 855,P0.0001,Overall survival (%),Days,Death, Stroke or MI,1,518 1,381 913 896 872 8461,533 1,377 908 891 868 845,Overall survival (%),P=0.64,Days,Major Adverse Cardiac and Cerebrovascular Events,1,518 1,153 729 691 657 6161,533 1,332 867 846 812 785,P2xConcomitant cardiac surgery,SYNTAX Inclusion Criteria,3-vessel disease and/or left main disease Total occlusion without time limitation Previous stroke 1 month Renal and respiratory insufficiency Decreased pump function Myocardial ischemia (unstable-silent-stable) Patients with comorbidity,Real world patient population,PCI n=198,TAXUS* n=903,CABG n=897,vs,CABG n=1077,no f/u n=428,5yr f/u n=649,Two Registry Arms N=1275,Randomized Arms N=1800,Heart Team (surgeon & interventionalist),Amenable for only one treatment approach,Amenable for both treatment options,Stratification: LM and Diabetes,LM 33.7%,3VD 66.3%,LM 34.6%,3VD 65.4%,23 US Sites,62 EU Sites,+,SYNTAX Trial Design,*TAXUS Express,Cumulative rate (%),SYNTAX: Outcomes,NEJM 360(10), 2009,Cumulative rate (%),Death from Any Cause,Death from Any Cause, Stroke, or MI,Repeat Revascularization,Major Adverse Cardiac or Cerebrovascular Event,Months since randomization,Cumulative rate (%),Cumulative rate (%),Months since randomization,P=0.37,P=0.99,3.5,P0.001,P=0.002,Months since randomization,Months since randomization,PCI,CABG,4.4,PCI,7.7,7.6,CABG,PCI,CABG,13.5,5.9,17.8,12.4,PCI,CABG,SYNTAX CABG/PCI Registries,SYNTAX appendix: NEJM, 2009,Reasons for CABG,Complex anatomy 70.9% Untreatable chronic 22.0% total occlusion Unable to take 0.9% anti-platelet medications Patient refused PCI 0.5% Other 5.7%,Reasons for PCI,Comorbidity 70.7% No graft material 9.1% Patient refused CABG 5.6% Small or poor quality 1.5% of distal vessel Other 13.1%,n=644,n=192,SYNTAX Score,Number & location of lesions,Tortuosity,Thrombus,Bifurcation,Total Occlusion,Diffuse,Left Main,Dominance,SYNTAX Score,