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Primary PCI Tips and tricks
D. Avramides, FESC
G. Gennimatas, Athens
Δεν ζχω οικονομικό ή άλλο όφελοσ
από κάποια από τισ εταιρείεσ χορηγοφσ του ςυνεδρίου
• afford a couple of minutes for an echo, in order to:• rule out other possible diagnoses
• aortic dissection • pericarditis • PE
• make a rough estimate of LV and valve function• localize the IRA territory • check for mechanical complications
before PPCI
Radial vs Femoral in STEMI: RIFLE-STEACS randomized
Romagnoli, JACC; in press
NNT to avoid one case of spasm: 18 (95% confidence interval 12.9-26.6)
Moderate procedural sedation and opioid analgesia during transradial coronary interventions to prevent spasm
a prospective randomized study
Deftereos, Giannopoulos, Raisakis, Hahalis, Kaoukis, Kossyvakis, Avramides, Pappas, Panagopoulou, Pyrgakis,Alexopoulos, Stefanadis, Cleman. JACC Cardiovascular Interventions: in press
Treatment group Controls P value
Spasm 2.6% 8.3% <.001
Access site crossover 9.9% 15% =0.001
Patient discomfort score 18.8% 27.4% <0.001
2,013 pts randomized to fentanyl 0.5 μg/kg + midazolam 1 mg IV over 2 min
Radial access in PPCI in the HORIZONS-AMI trial
Genereux, Eurointervention 2011;7:905-16
The lowest rates of adverse events occurred in patients randomised to bivalirudinwho underwent PCI by TR access
Steg, European Heart Journal 2012; 2012;33:2569-2619
before PPCI• evaluate the (presumably) non-IRA before PCI
the presumed culprit may not be actually the culprit
• checking the other arteries from the start may • actually save time • provide additional information, i.e. through collaterals
• if no doubt concerning the IRA and catheterization of the non-IRA takes long (“5-min rule”) proceed to PPCI (evaluate the non-IRA post PPCI)
• INFERIOR WALL AMI, TRANFERRED POST SUCCESSFUL TT, WITH POST-MI ANGINA• MULTIPLE (>15) CARDIOVERSIONS/DEFIBRILATIONS FOR VT/VF
PPCI (BMS) CABG later
Difficult IRA identification In Primary PCI
Echo might help!though, it may not localize convincingly the IRA (segmental overlap , preserved sub-epicardial contraction, previous infarction …)
The angiographic differences between CTO and Acute Occlusion may not help (tapered vs blunt occlusion, presence of thrombus, presence of collaterals)
If no way to conclude, guess and proceed! If ischemia persists after PCI, consider to proceed to the other lesion
Steg, European Heart Journal 2012; 2012;33:2569-2619
IV enoxaparin or UFH in PPCI: the randomised ATOLL trial
Montalescot, Lancet 2011; 378: 693–703
UFH+IIb/IIIa vs bivalirudin in AMI HORIZONS-AMI 3-y results
Stone, Lancet 2011; 377: 2193–204
major bleeding cardiac death
re-MI stent thrombosis
Stent Thrombosis after PPCI HORIZONS-AMI
Dangas, Circulation 2011;123:1745-1756
Steg, European Heart Journal 2012; 2012;33:2569-2619
No-Reflow
Levine, JACC 2011; 58: e44-e122
Steg, European Heart Journal 2012
• INFERIOR WALL AMI, TRANFERRED POST SUCCESSFUL TT, WITH POST-MI ANGINA• MULTIPLE (>15) CARDIOVERSIONS/DEFIBRILATIONS FOR VT/VF
post BMS 4.0*26
post Export
post NTG + NTP IC
IC vs IV bolus abciximab during PPCI: AIDA randomized trial
Thiele, Lancet 2012; 379: 923–31
death, re-MI, CHFdeath
re-MI CHF
Stent Thrombosis after DES in PPCI. The Importance of Thrombus Burden
Sianos, JACC 2007;50:573–83
Thrombus Aspiration during PPCI TAPAS 1-y FU
Vlaar, Lancet 2008; 371: 1915–20
Steg, European Heart Journal 2012; 2012;33:2569-2619
death death/re-MI
• Guiding inner lumen diameter ≥ 0.070“*aspiration catheters cannot be advanced when 2 wires in 0.070“ guiding (6F)
• Good co-axial position of the guiding catheter • enables good backup • minimizes the risk of systemic embolization- if position inadequate using the radial access, consider crossover to femoral
Manual Thrombectomy
• Start aspiration 20 mm proximal to the lesion, advance slowly• If passage through the lesion is not possible, a small balloon inflation is allowed
• Go slowly through the lesion following the blood coming into the syringe • If blood does not come into the syringe
- the aspiration catheter obstructs the coronary artery - the aspiration catheter is obstructed with thrombus
• withdraw the aspiration catheter slowly under continuous negative pressure until blood comes freely into the syringe, then advance again
• if blood does not come into the syringe, or when the syringe is about to get filled up, remove the aspiration catheter under continuous negative pressure
• Check pressure from the guiding catheter – thrombus may have migrated into the guiding catheter
• Aspirate the guiding catheter (always, but especially if pressure dampened) • If blood cannot be aspirated through the guiding
it is very likely that thrombus has migrated thereIn that case, remove the guiding under (-) pressure
• Make 2-3 passages
Manual Thrombectomy
be focused!!
AMI treated with PPCI using Only an Aspiration Catheter
Avramides, J INVASIVE CARDIOL 2008;20:E177–E179
LM Thrombus as a complication of Thrombectomy during PPCI
Alazzoni, J INVASIVE CARDIOL 2011;23:E9–E11
• other devices (balloons, microcatheters, IVUS)have the potential to bring thrombus back into the LM - the comparative risk with thrombectomy devices is unknown
Thrombus Aspiration complicated by systemic embolization
Lin , Circ J 2009; 73: 1356 – 1358
after ballooning
aspiration resulted in further migration
of the thrombus
large infarction of the territory of the right middle cerebral artery
Stroke
Bavry, European Heart Journal 2008;29, 2989–3001
after ballooning the thrombus
has migrated proximally
Thrombus Aspiration complicated by systemic embolization
Lin , Circ J 2009; 73: 1356 – 1358
angiography using the femoral
• no clot retrieved from Thrombuster 7F• blood could not be aspirated from the guiding• guiding was removed being maintained in (-) pressure• blood could not be aspirated through the sheath• the sheath was removed maintained in (-) pressure • no clot was found inside the sheath, the radial pulse was lost
lesion stented
UFH for 3 days, then warfarin3 months later radial completely patent
RCA ostial thrombotic occlusion in AMI
Izgi, EuroIntervention 2012;8:282-289
Direct Stenting vs Stenting after predilatation in PPCI Analysis from the HORIZONS AMI
Möckel, Am J Cardiol 2011;108:1697–1703
Intracoronary TNK after failed aspiration thrombectomy
Gallagher, Catheterization and Cardiovascular Interventions 2012;80:835–837
following aspiration thrombectomy
18 hr after TNK IC and abciiximab 12h
9 weeks later
Alteplase IC for extensive coronary artery thrombus
• The tip of the Tracker was positioned in the middle of the thrombus
• Alteplase 1 mg/ml saline was injected through the Tracker (10 mg bolus, followed by an infusion of 50 mg over 20 min) The thrombus completely dissolved distal to the Tracker (panel B)
• The Tracker was withdrawnproximal to the remaining thrombus,and a further 20 mg was infused over 10 minutes
Hippisley-Cox, Heart 2006
a very large thrombus burden in the infarct-related artery
Musiałek, EuroIntervention 2011;7:754-763
7 Fr Export
thrombolysis set aside due to recent history
of unexplained GI bleeding
4w later
• stent deferred due to high residual thrombus burden
• UFH for 24 hours then low-dose enoxaparin (100 mg) for 5 dwhen the patient self-discharged
Anterior AMI, started 2 ½ hours ago. Before angiography ST-elevation and pain resolved
after 72h with aspirin, IIb/IIIa and fondaparinux, asymptomatic
after Exportafter aspirations with 7F guiding
20 min post TNK ICafter 13 days of
lepirudin/bivalirudin
Abciximab IC and Aspiration Thrombectomy in Anterior AMI The INFUSE-AMI Randomized Trial
Stone, JAMA 2012;307:1817-1826
bolus of abciximab was administered locally at the site of the infarct lesion via the ClearWay RX Local Therapeutic Infusion Catheter,
a microporous “weeping” PTFE balloon mounted on a 2.7F rapid exchange catheter
Abciximab IC and Aspiration Thrombectomy in Anterior AMI The INFUSE-AMI Randomized Trial
Stone, JAMA 2012;307:1817-1826
bolus of abciximab was administered locally at the site of the infarct lesion via the ClearWay RX Local Therapeutic Infusion Catheter,
a microporous “weeping” PTFE balloon mounted on a 2.7F rapid exchange catheter
appendix
Radial vs Femoral access in STEMI: RIVAL
Mehta, JACC; in press
DeathCardiovascular Death, MI, Stroke, or
Non–CABG Major Bleeding
TR vs TF in PPCI: a systematic review and meta-analysis
Jang, EuroIntervention 2012; online publish-ahead-of-print May 2012
MACE
Mortality
Radial access in PPCI in the HORIZONS-AMI trial
Genereux, Eurointervention 2011;7:905-16
Staged vs “One-Time” Multivessel PCI in AMI
Analysis From the HORIZONS-AMI
Kornowski, J Am Coll Cardiol 2011;58:704
Bivalirudin prolonged infusion (4h, 0.25 mg/kg/h) post PPCIPROBI VIRI 2
Cortese, Am J Cardiol 2011;108:1220 –1224
>70% ST-segment resolution within 90 min after PCI
IIb/IIIaprolongedbivalirudin bivalirudin
Steg, European Heart Journal 2012; 2012;33:2569-2619
Steg, European Heart Journal 2012; 2012;33:2569-2619
No-Reflow• inadequate myocardial perfusion after successful mechanical opening of the IRA• in up to 10% of cases of primary PCI • increased 30 day mortality if not adequately treated (32% vs. 2.8%, p<.0.001)• microvasculature dysfunction or obstruction
Levine, JACC 2011; 58: e44-e122
Steg, European Heart Journal 2012
Berg, Current Cardiology Reviews, 2012, 8, 209-214
IC vs IV bolus abciximab during PPCI
Thiele, Lancet 2012; 379: 923–31
Meta-analysis of studies comparing IC vs IV abciximab bolus during PPCI
Death
MI
High-dose adenosine IC for myocardial salvage during PPCI
Desmet, European Heart Journal 2011;32:867–877
4 mg adenosine in 5 ml of 0.9% NaClthrough the central lumen of an OTW balloon, into the distal vascular bed, over 1 min
MRI at days 2-3 MRI at 4 months
Complications
Patel, JAMA 2011;326:1329
IABP and infract size in patients with anterior AMI without shockCRISP AMI
IABP and infract size in patients with anterior AMI without shock - CRISP AMI
Patel JAMA 2011;326:1329
Steg, European Heart Journal 2012; 2012;33:2569-2619
IABP Support for AMI with Cardiogenic Shock, IABP-SHOCK II Trial
Thiele, N Engl J Med 2012
IABP Support for AMI with Cardiogenic Shock, IABP-SHOCK II Trial
Thiele, N Engl J Med 2012
Steg, European Heart Journal 2012; 2012;33:2569-2619
If patient surgical candidate, consider POBA on culprit vessel - Is it safe to buy time?
Steg, European Heart Journal 2012; 2012;33:2569-2619
Thrombectomy and embolic protection devices in AMIa comprehensive meta-analysis of randomized trials
Bavry, European Heart Journal 2008;29, 2989–3001
mortality
Thrombectomy and embolic protection devices in AMIa comprehensive meta-analysis of randomized trials
Bavry, European Heart Journal 2008;29, 2989–3001
Stroke
massive thrombus embolisation in the LM during PCI for CTO
Geraci, EuroIntervention 2012;8:866-875
after withdrawal of the microcatheter
• Blood aspiration from the XB guiding catheter, then through an aspiration catheter (Pronto V3)until free clear blood came out and the pressure wave was normalized
• The guiding catheter was then removed under continuous aspiration
MGuard (micronet mesh–covered stent) in STEMI MASTER Randomized Trial
Stone, JACC 2012;60:1975–84
p value
MGuard (micronet mesh–covered stent) in STEMI MASTER Randomized Trial
Stone, JACC 2012;60:1975–84
CMRI substudy results at days 3 and 5
Clinical events at 30d FU
AngioJet Rheolytic Thrombectomy before Direct Stenting vs Direct Stenting alone in PPCI The JETSTENT Trial
Migliorini, JACC 2010;56:1298–306
Co-primary end points: early ST-segment resolution and 99mTc-sestamibi infarct size
evidence of statistical significance:• 0.05 by both co-primary end points• 0.025 for a single primary end point
“Although the primary end points were not met, these results support the use of RT before stenting in PPCI and evidence of thrombus”
PCI for Stent Thrombosis OPTIMIST multicentre registry
Burzotta, European Heart Journal 2008;29:3011
110 consecutive pts TIMI 2-3 in 88%, optimal angiographic reperfusion (TIMI 3 + MBG 2-3) in 64%
death MACE
30-day 12% 21%
6-month 17% 30%
Clinical outcome similar for BMS & DES ST
6-month recurrent ST:stent vs no stent: 26 vs 10%, p=0.04
Deamen , TCT 2011preliminary results
Treating stent thrombosis: 373 cases, Thoraxcenter 1999-2011
Delayed Arterial Healing at Culprit Sites After DES for STEMIAn Autopsy Study
Nakazawa, Circulation. 2008;118:1138-1145
suggest an increased risk of thrombotic complications
DES vs BMS in PPCI: meta-analysis of randomized trials
De Luca, Arch Intern Med 2012;172:611-21
PES vs BMS in AMI HORIZONS-AMI 3-y results
Stone, Lancet 2011; 377: 2193–204
TLR all patients
TLRpatients not undergoing routine
13-month angiographic F-U
mortality stent thrombosis
DES vs BMS in PPCI Meta-analysis of 15 randomized trials
Kalesan, European Heart Journal 2012;33,977–987
Predictors of Early, Late, and Very Late Stent Thrombosis after PPCI with BMS and DES
Brodie, JACC Intv 2012;5:1043–51
Predictors of Early, Late, and Very Late Stent Thrombosis after PPCI with BMS and DES
Brodie, JACC Intv 2012;5:1043–51
Multivariable Predictors of Early, Late, Early or Late, and Very Late ST
reduced ST with EES vs BMS in PPCI: EXAMINATION, 1y FU
Sabate, Lancet 2012; 380: 1482–90
death, re-MI, revascularisation
TLR
stent thrombosis
Stent Thrombosis of EES compared with Early-Generation DES A Prospective Cohort Study
Raber, Circulation. 2012;125:1110-1121
Stent Thrombosis of EES compared with Early-Generation DES A Prospective Cohort Study
Raber, Circulation. 2012;125:1110-1121