Professor Martin T Rothman

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PCI or CABG?
Professor Martin T Rothman Director Cardiac
Research Development Barts The London NHS
Trust London, England
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PCI or CABG? Silly question
Professor Martin T Rothman Director Cardiac
Research Development Barts The London NHS
Trust London, England
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SURGERY
X
PCI or CABG?
Professor Martin T Rothman Director Cardiac
Research Development Barts The London NHS
Trust London, England
4
Unprotected left main coronary stenting
immediate and medium-term outcomes of 140
elective patients
per cent

• 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

98
89
72
66
1
6
12
Months
Silvestri M et al (personal communication) JACC
2000 (In press)
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Inoperable Coronary artery disease How may we
manage
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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
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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
8
New NOGA-Guided PICVA Software
Live Mapper
Live TA

• Target Mode
• Live Mapper in vein
• Mapper acts as reference
• More stable, reproducible
• Less complicated, faster procedure

Transvascular Inc, with permission
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The Cardiac Valves Can they be replaced
percutaneously.
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Percutaneous Valve Technologies Inc. NJ, USAThe
valve was implanted on April 16th, 2002 by Dr
Alain Cribier
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Percutaneous Valve Technologies Inc. NJ, USAThe
valve was implanted on April 16th, 2002 by Dr
Alain Cribier
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Percutaneous Valve Technologies Inc. NJ, USAThe
valve was implanted on April 16th, 2002 by Dr
Alain Cribier
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Percutaneous Valve Technologies Inc. NJ, USAThe
valve was implanted on April 16th, 2002 by Dr
Alain Cribier
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Percutaneous Valve Technologies Inc. NJ, USAThe
valve was implanted on April 16th, 2002 by Dr
Alain Cribier
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Abdominal Aortic and Thoracic Aneurysms Can we
treat percutaneously
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Pre-Op
Post-Op
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Stent Graft in Delivery System
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Part Deployed
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Part Deployed
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Mitral regurgitation Can we treat percutaneously
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Mitral ring CinchFirst Human Use

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

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C-Cure First Human UseReduction in MR Jet On LV
Angiogram
4MR
LA
LV
End Diastole
Mid Systole
End Systole
2-3MR
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C-Cure First Human UseReduction in Valve Area
on 2-D Echo
Pre-Cinch 6.80 cm2
Post-Cinch 5.95 cm2
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C-Cure First Human UseReduction in MR Area on
Color Doppler
Pre-Cinch 9.64 cm2
Post-Cinch 4.04 cm2
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SURGERY
X
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
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CABG (isolated) Percutaneous interventions
UK Cardiac Surgical Register British
Cardiovascular Intervention Society
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CABG (isolated) Percutaneous interventions
UK Cardiac Surgical Register British
Cardiovascular Intervention Society
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Guidance on Coronary Artery Stents in the
Treatment of Ischaemic Heart Disease (May 11th
2000)

• 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

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CABG
Diffuse MVD
LMS MVD
MVD Complex
LMS
MVD
Complex
CTO
SVD
PCI
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CABG
Diffuse MVD
LMS MVD
MVD Complex
LMS
MVD
Complex
CTO
SVD
PCI
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Single v Multi-vessel diseaseCABG PCI
95.4
82.5
UK Cardiac Surgical Register British
Cardiovascular Intervention Society
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Single v Multi-vessel diseaseCABG 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
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!! HEALTH WARNING !! Some of the numbers and all
of the opinions that follow are mine!!
Martin T Rothman BCIS 2002
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Guidance on Coronary Artery Stents in the
Treatment of Ischaemic Heart Disease (May 11th
2000)

• 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

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!! HEALTH WARNING !! Some of the numbers and all
of the opinions that follow are mine!!
Martin T Rothman BCIS 2002
39
!! HEALTH WARNING !! Some of the numbers and all
of the opinions that follow are mine!!
Martin T Rothman BCIS 2002
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!! HEALTH WARNING !! Some of the numbers and all
of the opinions that follow are mine!!
Martin T Rothman BCIS 2002
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NSF
!! HEALTH WARNING !! Some of the numbers and all
of the opinions that follow are mine!!
Martin T Rothman BCIS 2002
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BLT

NSF
(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
43
!! HEALTH WARNING !! Some of the numbers and all
of the opinions that follow are mine!!
Martin T Rothman BCIS 2002
44
!! HEALTH WARNING !! Some of the numbers and all
of the opinions that follow are mine!!
Martin T Rothman BCIS 2002
45
!! HEALTH WARNING !! Some of the numbers and all
of the opinions that follow are mine!!
Martin T Rothman BCIS 2002
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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!

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