PCI or CABG?

Professor Martin T Rothman

Director Cardiac Research & Development
Barts & The London NHS Trust
London, England

PCI or CABG?
Silly question
Professor Martin T Rothman
Director Cardiac Research & Development
Barts & The London NHS Trust
London, England

SURGERY

PCI or CABG?
Professor Martin T Rothman
Director Cardiac Research & Development
Barts & The London NHS Trust
London, England

Unprotected left main coronary stenting:

immediate and medium-term outcomes of 140
elective patients
140 LMS patients (Gp I:
47 high risk & Gp II: 93
low risk for CABG)
Three vessel disease
47%
Occluded RCA 14%
Debulking 6%
Early death I: 0% & II: 9%
TLR (6/12) I: 10.5% &
II: 21%

100

per cent
98%
89%

80

72%
66%

60
40

Death (Good)
MACE (Good)
Death (Poor)

20

MACE (Poor)

Months

12

Silvestri M et al (personal communication)

JACC 2000 (In press)

Inoperable Coronary artery disease

How may we manage

PICVA - Basic Concept

Percutaneous In-Situ Coronary Venous Arterialization

Selective Coronary Vein

Perfuses Myocardium
Arterial Supply From
Proximal Coronary Artery
Single Connection
Made Percutaneously
Vein Blocked Proximally
Bypasses Artery Completely
Transvascular Inc, with permission

NOGA Guided TransAccess

Two Catheters Used:
One Positioned In Target Vessel
One Placed In Source Vessel

Using NOGA Guidance

TransAccess Catheter Pointed
Toward Target Catheter
Needle Advanced
Wire Delivered Into Target Vessel
Transvascular Inc, with permission

New NOGA-Guided PICVA Software

Live Mapper

Live TA

Target Mode

Transvascular Inc, with permission

Live Mapper in vein

Mapper acts as reference
More stable, reproducible
Less complicated, faster procedure

The Cardiac Valves

Can they be replaced
percutaneously.

Percutaneous Valve Technologies Inc. NJ, USA

The valve was implanted on April 16th, 2002 by Dr Alain Cribier

Percutaneous Valve Technologies Inc. NJ, USA

The valve was implanted on April 16th, 2002 by Dr Alain Cribier

Percutaneous Valve Technologies Inc. NJ, USA

The valve was implanted on April 16th, 2002 by Dr Alain Cribier

Percutaneous Valve Technologies Inc. NJ, USA

The valve was implanted on April 16th, 2002 by Dr Alain Cribier

Percutaneous Valve Technologies Inc. NJ, USA

The valve was implanted on April 16th, 2002 by Dr Alain Cribier

Abdominal Aortic and Thoracic

Aneurysms
Can we treat percutaneously

Pre-Op

Post-Op

Stent Graft in Delivery System

Part Deployed

Part Deployed

Mitral regurgitation
Can we treat percutaneously

Mitral ring Cinch

First Human Use

September, 2001
3 Cases
Excellent results
Reduction in MR noted
No complications with access,
delivery, deployment (cinching)

C-Cure First Human Use

Reduction in MR Jet On LV Angiogram
4+MR
LA
LV

End Diastole

Mid Systole

End Systole
2-3+MR

C-Cure First Human Use

Reduction in Valve Area on 2-D Echo

Pre-Cinch
6.80 cm2

Post-Cinch
5.95 cm2

C-Cure First Human Use

Reduction in MR Area on Color Doppler

Pre-Cinch
9.64 cm2

Post-Cinch
4.04 cm2

SURGERY

PCI or CABG?
!! HEALTH WARNING !!
Some of the numbers and all of the opinions that follow are
mine!!
Professor Martin T Rothman
Director Cardiac Research & Development
Barts & The London NHS Trust
London, England

CABG (isolated) &

Percutaneous interventions
35000

BCIS
SCTS

30000
25000
20000
15000
10000
5000
0
'91 '92 '93 '94 '95 '96 '97 '98

UK Cardiac Surgical Register

British Cardiovascular Intervention Society

CABG (isolated) &

Percutaneous interventions
35000

BCIS
SCTS

30000
25000
20000
15000
10000
5000
0
'91 '92 '93 '94 '95 '96 '97 '98 '99 '00

UK Cardiac Surgical Register

British Cardiovascular Intervention Society

Surgical Activity UK
40000

Numbers of procedures

35000
30000
25000

Congenital

20000
15000

Valve

10000

CABG

5000
0
92

93

94

95

96

Years

97

98

99

00

Total Intervention UK
80000
70000

No of procedures

60000
50000
40000

PCI
Congenital
Valve
CABG

30000
20000
10000
0
92

93

94

95

96

Years

97

98

99

00

Guidance on Coronary Artery Stents in

the Treatment of Ischaemic Heart
Disease (May 11 2000)
th

patients with angina or who have had a

heart attack, who will be having balloon
angioplasty/PCI should now normally
receive a coronary artery stent
if a patient is suitable for both a PCI and
a coronary artery bypass graft (CABG),
then it may be considered preferable for
these patients to undergo a PCI with a
coronary artery stent, instead of a CABG

CABG
Diffuse MVD
LMS + MVD
MVD + Complex
LM
S MVD
Complex
CTO
SVD

PCI

CABG
Diffuse MVD
LMS + MVD
MVD + Complex
LM
S MVD
Complex
CTO
SVD

PCI

Single v Multi-vessel disease

CABG & PCI

95.4%

82.5%

UK Cardiac Surgical Register

British Cardiovascular Intervention Society

Single v Multi-vessel disease

CABG & PCI

95.4%

82.5
%

80%

UK Cardiac Surgical Register

British Cardiovascular Intervention Society

!! HEALTH WARNING !!
Some of the numbers and all of the opinions that follow are mine!!

Martin T Rothman BCIS 2002

PCI growth, surgery reduction

120000
100000

Numbers

80000

PCI
Congenital
Valve
CABG

60000
40000
20000
0
92 93 94 95 96 97 98 99 00

04 08 12

Years

!! HEALTH WARNING !!
Some of the numbers and all of the opinions that follow are mine!!

Martin T Rothman BCIS 2002

Guidance on Coronary Artery Stents in

the Treatment of Ischaemic Heart
Disease (May 11 2000)
th

patients with angina or who have had a

heart attack, who will be having balloon
angioplasty/PCI should now normally
receive a coronary artery stent
if a patient is suitable for both a PCI and
a coronary artery bypass graft (CABG),
then it may be considered preferable for
these patients to undergo a PCI with a
coronary artery stent, instead of a CABG

The changing face of intervention

200000

Numbers of procedures

180000
160000
140000

Failed Tx
PCI
Congenital
Valve
CABG

120000
100000
80000
60000
40000
20000
0
92 93 94 95 96 97 98 99 00

04 08 12

Years

!! HEALTH WARNING !!
Some of the numbers and all of the opinions that follow are mine!!

Martin T Rothman BCIS 2002

PCI with AMI

450000
400000
350000

Numbers

300000

AMI
PCI
Congenital
Valve
CABG

250000
200000
150000
100000
50000
0
92 93 94 95 96 97 98 99 00

04 08 12

Years

!! HEALTH WARNING !!
Some of the numbers and all of the opinions that follow are mine!!

Martin T Rothman BCIS 2002

Adult Interventions (PCI)

70000

1200

adult interventions
intervent/mill

Numbers

50000

1000
800

40000
600
30000
400

20000

Interventions/million

60000

200

10000
0

0
92

93

94

95

96

97

98

99

00

04

08

Years

!! HEALTH WARNING !!
Some of the numbers and all of the opinions that follow are mine!!

Martin T Rothman BCIS 2002

Adult Interventions (PCI)

70000

1200

adult interventions
intervent/mill

Numbers

50000

1000
800

40000

NSF

30000

600
400

20000

Interventions/million

60000

200

10000
0

0
92

93

94

95

96

97

98

99

00

04

08

Years

!! HEALTH WARNING !!
Some of the numbers and all of the opinions that follow are mine!!

Martin T Rothman BCIS 2002

Adult Interventions (PCI)

*BLT

70000

adult interventions
intervent/mill

50000

1000
800

40000

NSF

30000

600
400

20000

Interventions/million

60000

Numbers

1200

200

10000
0

0
92

93

94

95

96

97

98

Years

99

00

04

08

(BLT = Barts and the London)

!! HEALTH WARNING !!
Some of the numbers and all of the opinions that follow are mine!!

Martin T Rothman BCIS 2002

Adult intervention (PCI) including failed ThX or

AMI
180000

3500

160000

3000

Numbers

120000

adult interventions
intervent/mill

2500

100000

2000

80000

1500

60000

1000

40000

500

20000
0

Intervention/mill

140000

0
92 93 94

95 96 97 98 99 00

Years
!! HEALTH WARNING !!
Some of the numbers and all of the opinions that follow are mine!!

04 08 12
Martin T Rothman BCIS 2002

Adult interventionists
700
600

interventionists @100
interventionists @150
interventionists @250

Numbers

500
400
300
200
100
0
92

93

94

95

96

97

98

99

00

04

08

Years

!! HEALTH WARNING !!
Some of the numbers and all of the opinions that follow are mine!!

Martin T Rothman BCIS 2002

Adult interventionists with failed ThX or AMI

4500

interventionists @100

4000
3500

interventionists @150

Numbers

3000
2500

interventionists @250

2000
1500
1000
500
0
92

93

94

95

96

97

98

99

00

04

08

12

Years

!! HEALTH WARNING !!
Some of the numbers and all of the opinions that follow are mine!!

Martin T Rothman BCIS 2002

PCI or CABG ? my view

PCI will increase

PCI will take CABG cases

Because of Drug Eluting Stents

Because of improving skill and equipment

CABG will decrease

The CABG we ask for will be more complex
But the surgeons will be less experienced

We need to participate in the development of PCI, not be lead by NSF BCIS lead
activity
Centres need to develop strategy for increasing volume
Less operators doing more
More operators doing less
Both. BCIS

lead activity
We need to address AMI BCIS lead activity
We must hope for an improved thrombolytic strategy that evolves quickly!