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In Diabetics with Ischemic Heart Disease CABG revascularization is always superior?
Dr. Paolo Ferrazzi
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DN, male, 65 yrNIDDM, HTBMI 283 vessel disease
What is the best OPTION?
CLINICAL SCENARIO
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Background• Major developments in CABG
– off-pump technique, less invasive approach, increased arterial revascularization and optimal perioperative care
• Major developments in PCI– improved technique, stent design, guide
wires, anti-platelet therapy, and drug-eluting stents
• Important to reassess the respective values of the two revascularization
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• 7812 patients• Median FU 6 years• 65%: 1 or 2 VD; all normal LV• 1233 with DM
• HR for CABG vs PCI in DM 0.70; p= 0.01
• Survival benefit of CABG increases with time
Lancet 2009; 373: 1190–97
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Scores ≤ 22 (n=136) Scores 23-32 (n=156)
Scores ≥ 33 (n=157)0
10
20
30
40
50
60
33.728.6
25.5
42.5 41.5
56.7
5y MACCE in DM (% pts)
CABG PES
p=0,38 p=0,078p<0,001
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FREEDOM TRIAL:PATIENTS WITH DIABETES
New England J. of Medicine, December 20, 2012; Vol. 367 No. 25
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Survival benefit with two IMA grafts?
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Bergamo experience 2012Diabetic and non Diabetic Patients
Patients n. 139
LIMA (%) 99%
BIMA (%) 43%
A RAD (%) 32%
Perioperative mortality 0.92
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Bergamo experienceSurgical options in diabetes
LIMA Pedicled + RIMA skeletonized in situ
LIMA + RIMA skeletonized in situ
LIMA in situ + RIMA (Y grafted)
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Actuarial survival unmatched diabetic pts
Actuarial survival propensity score–matched diabetic pts
Actuarial survival unmatched diabetic pts <65yr
Actuarial survival unmatched diabetic pts ≥65yr
p<0.001
p<0.001
P=0.006
P=0.014
Compared with SIMA grafting, BIMA grafting in propensity score–matched patients provides diabetics with enhanced survival without any increase in perioperative morbidity or mortality
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Conclusions• CABG seems to have better long-term results in
complex multivessel diabetic patients• Two mammary seems to be better than one• Adding radial artery to revascularization strategy
could further improve results
The optimum revascularization strategy for each individual patient will depend on a careful
consideration of the risks and benefits of each procedure in conjunction with the baseline risk profile
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PCI
CABG
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SYNTAX Trial: top 15 Enrollers
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P=0.001P<0.001