Thursday, September 03, 2009


It was with some fanfare last year, at the same meeting that Dr Patrick Serruys announced to a packed audience the 1 year results of the SYNTAX trial. This is a landmark trial of 1,800 patients with left main stem disease randomised ( not blinded ) to receive either PCI with the Taxus ( DES ) or CABG. Cardiac surgeons were very happy to know that the 1 year result showed that CABG was superior to PCI, overall, in the treatment of Left Main Stem Disease. But cardiac interventionist, led by Dr Serruys was equally happy to note that over 1 year, in the subset of left main stem disease patients with less complex disease ( subset analysis ), PCI was better than CABG, except perhaps in diabetics. So everyone had something good, from the SYNTAX trial, so the debate went on. In fact, on the basis of SYNTAX and the LE MANS registry, the ESC may review the clinical guidelines to make PCI a class 2A indication in the management of left main stem disease.
Well, just 3 days ago, in Barcelona, at the just concluded ESC ( European Society of Cardiology ) meeting , Dr Pieter Kappatein ( Erasmus Medical Center, Rotterdam ), ( I wonder where Patrick Serruys was ), presented on behalf of the SYNTAX investigators, the 2 year follow-up of the same cohort of patients. In summary, the grafts continue to divurge, meaning that over the next 12 months, CABG continued to do better ( can you hear the surgeons sniggering ) then PCI. There were more heart attacks in the PCI group and of course more repeat revascularisation. Strokes, the main downside to CABG in the 1 year result, stabilised over the next 12 months and that graph remain basically the same.
What all this jargon means is that except for the very simple left main stem, and also those left main patients who do not want cardiac surgery, or who cannot undergo cardiac surgery, CABG should be the prefered mode of therapy. Meaning that although PCI can be done, over 2 years, there were more heart attacks and repeat PCI. I suppose interventionist will find comfort in the findings that although there was an increase in heart attack rates, the overall death rates were the same in both arms, even after two years. You see, all is not lost for PCI. Please remember that I am an interventionist.
Locally, having travelled the country and seen the work, and also having reviewed cases at many meetings, local cardiac interventionist do do quite alot of left main stem PCI. At one local meeting, I commented that they were doing PCI that I would not think of touching. Well I suppose the usual indication is that the patient did not want surgery. That is always a mood point. If the interventionist paints a picture that PCI is possible and is just as good, then I believe most patients will choose PCI, being less invasive. But if they are advised that PCI has know dangers, including, increase procedural risk, increase rates of heart attacks, and increase repeat PCIs over 2 years, and they be given time to reconsider ( not an ad hoc, I hope ) then the decision may be different.
Well, at the end of the day, the patient must decide and we are trying to educate patients so that they can make a good informed decision. That is the aim of this blog.

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