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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


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

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


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

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

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


IABP Support for AMI with Cardiogenic Shock, IABP-SHOCK II Trial

Thiele, N Engl J Med 2012

If patient surgical candidate, consider POBA on culprit vessel - Is it safe to buy time?


Thrombectomy and embolic protection devices in AMIa comprehensive meta-analysis of randomized trials


mortality

Thrombectomy and embolic protection devices in AMIa comprehensive meta-analysis of randomized trials


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

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