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Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
Ppci culprit vs mv acad card 2013 mumbai
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Ppci culprit vs mv acad card 2013 mumbai

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  • 1. Primary PercutaneousCoronary Interventions in multi vessel disease Dr. Dev Pahlajani MD,FACC,FSCAI Chief of Interventional Cardiology- Breach Candy Hospital and Consultant Cardiologist- Nanavati Heart Institute, Mumbai
  • 2. INF MI RCA LAD CX
  • 3. INF MI MVK RCA LAD CX
  • 4. MVK PPCI RCA LAD CX
  • 5. MVK RCA LAD CX INF MI
  • 6. ANT MI LAD OM
  • 7. MER ANT MI LAD OM
  • 8. MER ANT MI LAD CX
  • 9. PPCI-culprit VS MV VS staged THREE STRATEGIES1)CULPRIT ONLY: PCI confined to culprit vessel only2)MV-PCI: all interventions during same procedure3)STAGED PCI:PPCI of culprit vessel during index procedure. Non culprit PCI subsequently
  • 10. Culprit Vessel Only Versus Multivessel and Staged Percutaneous CoronaryIntervention for Multivessel Disease in Patients Presenting With ST-Segment Elevation Myocardial Infarction Pieter J. Vlaar, Karim D. Mahmoud, ; David R. Holmes, Gert van Valkenhoef, Hans L. Hillege, Iwan C.C. van der Horst, et al J Am Coll Cardiol. 2011;58(7):692-703.
  • 11. CULPRIT VS MV VS STAGED PCI 2656 abstracts retrieved from electronic database 2607 abstracts excluded 49 complete articles assessed according to selection criteria •31 studies excluded based on: •25 No STEMIFlow diagram of study •4 No stratification to at least 2 ofinclusion and exclusion. the 3 PCI strategiesPCI = percutaneous coronary •1 Comparing complete vs.intervention; incomplete revascularizationSTEMI = ST-segment •1 Comparing 2 strategies forelevation myocardialinfarction. tandem lesions in culprit vessel 18 studies were included J Am Coll Cardiol. 2011;58(7):692-703.
  • 12. Culprit PCI Versus MV-PCI and Staged PCI for Long-Term Mortality Odds ratio, IV Random Culprits only MV PCI ODDs 95% CI PCI Ratio Study Event Total Event Total 95% CI Prospective studies Di Mario,2004 0 17 1 52 0.98 Khatab, 2008 3 45 2 25 0.82 Politi, 2010 13 84 6 65 1.8 Retrospective studies Corpus,2004 42 354 5 26 0.57 Dzeiwierz , 57 707 11 70 0.47 2010 Hannan,2010 28 503 36 503 0.76 Favours culprit PCI/Favours MV PCI Schaaf, 2010 66 124 22 37 0.78 Toma,2010 111 1979 27 216 0.42J Am Coll Cardiol. 2011;58(7):692-703. Total events 356 164
  • 13. Prognostic Impact of StagedVersus “One-Time” Multivessel Percutaneous Intervention in Acute Myocardial Infarction HORIZONS-AMI Trial Ran Kornowski, Roxana Mehran, George Dangas, Eugenia Nikolsky, Abid Assali, Bimmer E. Claessen, et al J Am Coll Cardiol. 2011;58(7):704-711
  • 14. STUDY PROTOCOL-A3602 pts with STEMI with symptom onset <= 12 hoursRandomized into UFH +/- GP II b/III a inhibitor vs. Bivalirudinmonotherapy (+/- provisional GP IIb/IIIa) and to BMS vs. Taxus Stent 668 patients (18.5%) with multivessel CAD underwent PCI of the culprit and non culprit lesion Therapeutic strategySingle/ One time PCI (N= Staged PCI ( N=393)275) 30 days, 1 year outcomes All patients undergoing MV PCI J Am Coll Cardiol. 2011;58(7):704-711
  • 15. STUDY PROTOCOL-B 668 patients with STEMI and multi vessel PCI in HORIZONS AMISingle/One time PCI (N=275) Staged PCI (N=393) Excluding from both groups all pts in whom the second lesion was in a vessel with TIMI 0- 2 flow ‘True elective’ MVSingle/One time PCI PCI cases Staged PCI (N=77)(N= 165) 30d, 1 year outcomes Patients with true elective MV PCI in the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) trial. J Am Coll Cardiol. 2011;58(7):704-711
  • 16. Clinical Outcomes of Patients With Multivessel Disease Time to mortality J Am Coll Cardiol. 2011;58(7):704-711
  • 17. Clinical Outcomes of Patients With Multivessel Disease Cardiac mortality J Am Coll Cardiol. 2011;58(7):704-711
  • 18. Clinical Outcomes of True Elective PCI-Treated Patients Time to mortality J Am Coll Cardiol. 2011;58(7):704-711
  • 19. Clinical Outcomes of True Elective PCI-Treated Patients Cardiac mortality J Am Coll Cardiol. 2011;58(7):704-711
  • 20. Multi-vessel disease in AMI• Multi-vessel disease occurs in 40-65% of patients with AMI• It confers higher risk in general and higher risk after intervention• PCI of the IRA is beneficial• The benefits of treatment of non-culprit vessels are unknown Kahn JK et al, JACC 1990;16:1089-96 Jaski BE et al, Am Heart J 1992;124:1427-33 Kahn JL et al, Am J Cardiol 1990;66:1045-8 Shihara M et al, Am J Cardiol 2002;90:932-6 Muller DW et al, Am Heart J 1991;121:1042-9 Keeley EC, Boura JA, Grines CL. Lancet 2003;361:967-8
  • 21. • More multi-vessel procedures are being done (in elective patients and non-STEMI ACS)• Multi-vessel stenting in the era of DES and GP IIb/IIIa inhibitors is delivering outcomes comparable with CABG
  • 22. The case for performing multi-vessel PCI during infarct angioplasty• Flow in non-IRA vessels is not normal and is worse in vessels with >50% stenosis• Slow flow in the non-IRA is associated with reduced non-IRA territory wall thickening, which improves when flow returns to normal• Enhanced function in the non-IRA territory confers a survival advantage• Patients often have multiple complex plaques• Coronary plaque instability can be a multi-focal process• These patients have higher event rates• Treatment of these unstable plaques may be beneficial• May be crucial in patients with cardiogenic shock• Simultaneous multi-vessel PCI may reduce vascular access and anti- coagulant related complications and reduce costs Grines CL et al. Circ 1989;80:245-53 Hochman JS et al, NEJM 1999;341:625-34 Gibson CM et al, JACC 1999;34:974-82 Goldstein JA et al, NEJM 2000;343:915-22 Santoro GM, Buonamici P. Am Heart J 1999;138:126-31 Asakura M et al, JACC 2001;37:1284-8 Gregorini L et al, Circ 1999;99:482-90 Hanratty CG et al, JACC 2002;40:911-6
  • 23. “Costs”• Multi-vessel PCI is more costly to the provider and the patient• Psychological and logistic problems• Staged PCI in the same hospital admission only attracts a single procedural cost
  • 24. The case against performing multi-vessel PCI during infarct angioplasty• Every PCI for every lesion carries a finite risk• Non-culprit lesion severity is often exaggerated during AMI• State of vasoconstriction• Enhanced thrombotic and inflammatory state persists for some time after an AMI• Longer more complex procedures (contrast nephropathy, haemodynamic instability)• Additional time, more radiation exposure• Additional cost of the index procedure• Benefits not proven Fuster V et al. Circulation 1990;82:47-59 Reilly MP et al. Circulation 1997;96:3314-20 Shah PK, Forrester JS. Am J Cardiol 1991;68:16-23C Bogaty P, et al. Am Heart J 1998;136:884-93 Stewart DJ et al. JACC 1991;18:38-43 Bogaty P et al, Circ 2001;103:3062-8 Hempel SL et al. Am J Physiol 1993;264:1448-57 Hanratty CG et al, JACC 2002;40:911-6 Ambrose JA, Weinrauch M. Arch Intern Med 1996;156:1382-94 Barrett TD et al, J Pharmacol Exp Ther 2002;303:1007-13 Haught WH et al. Am Heart J 1996;132:1-8
  • 25. Risk factors for contrast nephropathy • impairment • Congestive heart failure • Mitral regurgitation • Acute myocardial infarction • Dehydration • Gender (females>males) • Route of administration (I-A > I-V) • Diabetes? (probably dependent on co-existent renal damage) • Elderly? (ditto) • Concurrent use of NSAIDs and other nephrotoxic drugs • Widespread evidence of arterial disease • Hypotension • Hypoalbuminaemia
  • 26. Which other lesion(s) should you treat? Patients with follow-up angiograms after infarct angioplasty Hanratty CG et al, JACC 2002;40:911-6 n=48 Infarct angiogram Non-infarct P angiogram Nitrate 44 (92%) 20 (42%) <0.01 Statin 11 (23%) 40 (83%) <0.01 ACE-I 14 (29%) 45 (94%) <0.01 Infarct angiogram Non-infarct P angiogram Ref diam (mm) 3.1 (0.8) 3.0 (0.8) 0.3 MLD (mm) 1.53 (0.51) 1.78 (0.65) <0.001 % stenosis 49.3 (14.5) 40.4 (16.6%) <0.0001•Vasoconstriction at time of STEMI more likely an explanation than plaque regression or haemodynamic factors•If immediate revascularisation were attempted on all lesions >50%, this would prompt unnecessary PCI in 1:5 patients
  • 27. Staged Vs “One-time” Multivessel PCI In AMI: Staged PCI Total Mortality A deferred PCI strategy of non-culprit lesions should remain the standard approach, as multivessel PCI may Cardiac Mortality be associated with a greater hazard for mortality and stent thrombosis. Kornowski et al JACC 2011; 58:704–11
  • 28. MATRIX Trial 1:1 N>6,800 Angiography Radial Access Femoral AccessPCI 1:1 1:1 N~6,800 UFH±GPI UFH±GPI Bivalirudin Bivalirudin UFH±GPI UFH±GPI PI: Marco Valgimigli
  • 29. Staged Vs “One-time” Multivessel PCI In AMI: Staged PCI Total Mortality A deferred PCI strategy of non-culprit lesions should remain the standard approach, as multivessel PCI may Cardiac Mortality be associated with a greater hazard for mortality and stent thrombosis. Kornowski et al JACC 2011; 58:704–11
  • 30. Mortality: IRA Only vs. Multivessel vs. Staged PCI for MVD in STEMI Vlaar et al JACC 2011; 58:692–703
  • 31. Single Vs MV PPCI JACC 2011 Kornowski• SINGLE VESSEL: I YR MORTLITY 2.3% CARD.MORT 2.0% ST.THROMB. 2.3%• MV PPCI: 1 YR MORT. 9.2% CARD.MORT. 6.2% ST.THROMB 5.7%
  • 32. Mortality: IRA Only vs. Multivessel vs. Staged PCI for MVD in STEMI Vlaar et al JACC 2011; 58:692–703
  • 33. Multivessel PCI in infarct angioplasty  79 cases collected from 8 centres of multi-vessel PCI during infarct angioplasty  79 control cases of IRA only PCI in patients with multivessel disease (matched for age and Killip class)  Not confined to shock cases (only 28% Killip IV in both groups) Multivessel PCI Controls PGP IIb/IIIa 59.5% 62% NSStenting of IRA 70.9% 45.6% <0.001Core Lab analysis N=58 N=63Final TIMI 3 84.4% 79.3%IRA Dissection 3.4% 12.7%IRA Distal embolisation 1.7% 4.8%IRA Side branch closure 1.7% 1.6%Non-IRA Dissection 8.8%Non-IRA Distal embolisation 3.5%Non-IRA Side branch closure 1.8% Roe MT et al, Am J Cardiol 2001;88:170-3
  • 34. Multi-vessel PCI in infarct angioplasty Rescue PCI Primary PCI Multivessel Controls P Multivessel Controls P PCI (n=11) (n=18) PCI (n=68 (n=61)Death 18.2% 16.7% NS 25% 16.4% NSReMI 0% 0% 8.8% 1.6% 0.07CABG 9.1% 11.2% NS 4.4% 0% 0.10Rpt PCI 9.1% 0% NS 8.8% 11.5% NSComposite 27.3% 27.8% NS 35.3% 27.9% NSStroke 0% 5.6% NS 10.3% 0% 0.01 Roe MT et al, Am J Cardiol 2001;88:170-3
  • 35. Multi-vessel PCI in infarct angioplasty AMI (n = 8 2 0 ) S in g le v e s s e l d is e a s e M u lt iv e s s e l d is e a s e * (n = 3 1 4 ) (n = 5 0 6 ) P C I o f I R A o n ly M u lt iv e s s e l P C I (n = 3 5 4 ) (n = 1 5 2 ) P C I o f IR A a n d n o n IR A P C I o f IR A a n d n o n IR A w it h in s a m e p r o c e d u r e s t a g e d w it h in in d e x h o s p it a lis a t io n (n = 2 6 ) (n = 1 2 6 ) •Patients undergoing staged procedures at a second admission excluded •*Defined as stenosis ≥70% of ≥2 epicardial vessels or their major branches •If stent, clopidogrel 75mg od x at least 4 weeks Corpus RA et al, Am Heart J 2004;148:493-600
  • 36. Multi-vessel PCI in infarct angioplasty 1VD MVD P (n=314) (n=506) Age 60±13 63±13 0.001 DM 23 (7.3%) 89 (18%) <0.001 HT 121 (39%) 268 (53%) <0.001 Prior MI 24 (7.6%) 104 (20.3%) <0.001 GP IIb/IIIa 93 (30%) 183 (36%) 0.05 Corpus RA et al, Am Heart J 2004;148:493-600
  • 37. Multi-vessel PCI in infarct angioplasty 1VD (n=314) MVD (n=506) P30-day outcomesReMI 2 (0.6%) 16 (3.2%) 0.02TVR 4 (1.3%) 37 (7.3%) <0.001CABG 4 (1.3%) 32 (6.4%) <0.001Mortality 9 (2.9%) 38 (7.5%) 0.005MACE 15 (4.8%) 85 (17%) <0.0011-yr outcomesReMI 5 (1.6%) 30 (5.9%) 0.003TVR 30 (9.6%) 91 (18%) <0.001CABG 8 (2.6%) 51 (10%) <0.001Mortality 10 (3.2%) 59 (12%) <0.001MACE 41 (13%) 159 (31%) <0.001MV predictors of 1 yr mortality: Renal insufficiency, MV disease, EF≤40%, Age Corpus RA et al, Am Heart J 2004;148:493-600
  • 38. Multi-vessel PCI in infarct angioplasty Patients with multivessel disease IRA only (n=354) MV PCI (n=152) PSmoker 238 (67%) 83 (55%) 0.007GP IIb/IIIa 139 (39%) 44 (29%) 0.03Stent 307 (87%) 148 (97%) <0.00130-day outcomesReMI 2 (0.6%) 14 (9.2%) <0.001CABG 28 (8.0%) 4 (2.6%) 0.02MACE 52 (15%) 33 (22%) 0.0531-yr outcomesReMI 10 (2.8%) 20 (13%) <0.001TVR 53 (15%) 38 (25%) 0.007CABG 41 (12%) 10 (6.6%) 0.08Mortality 42 (12%) 17 (11%) 0.82MACE 98 (28%) 61 (40%) 0.006 MV analysis for1-yr MACE: MV PCI OR 1.67 (95%CI 1.10-2.54, p=0.01) Corpus RA et al, Am Heart J 2004;148:493-600
  • 39. Multi-vessel PCI in infarct angioplasty Multi-vessel procedures IRA only MVD Same MVD Staged, in- P (n=354) procedure (n=26) hospital (n=126)Hospital mortality 20 (5.6%) 5 (19%) 3 (2.4%) 0.00330-day outcomesReMI 2 (0.6%) 0 (0%) 14 (11%) <0.001TVR 28 (7.9%) 1 (3.8%) 8 (6.3%) 0.66CABG 28 (8.0%) 1 (3.8%) 2 (2.4%) 0.07Mortality 23 (6.5%) 5 (19%) 10 (7.9%) 0.06MACE 52 (14.7%) 6 (23%) 27 (21%) 0.151-yr outcomesReMI 10 (2.8%) 1 (3.8%) 19 (15%) <0.001TVR 53 (15%) 3 (12%) 35 (28%) 0.004CABG 41 (12%) 2 (7.7%) 8 (6.3%) 0.21Mortality 42 (12%) 5 (19%) 12 (9.5%) 0.36MACE 98 (28%) 9 (35%) 53 (41%) 0.02 Corpus RA et al, Am Heart J 2004;148:493-600
  • 40. Multi-vessel PCI in infarct angioplasty Conclusions Patients with MVD have worse outcomes Perform IRA PCI only Decisions about other vessels should be guided by objective evidence of significant residual ischaemia Further trials needed. Corpus RA et al, Am Heart J 2004;148:493-600
  • 41. Personal experience 2005
  • 42. Staged vs non-staged procedures in multivessel PCI (predominantly non-emergency) Staged (n=135) Nonstaged (n=129) PIn-hospital 3 (2.2%) 6 (4.6%) 0.28MACE1-yr outcomeQ MI 1 (0.7%) 5 (3.9%) 0.09TLR 23 (17.2%) 28 (21.9%) 0.34MACE* 35 (26.1%) 46 (35.9%) 0.08Total LOS (days) 3.56±1.49 2.24±1.89 <0.001* Staged procedure single independent predictor of lack of MACE at 1-yr (p=0.05) Nikolsky E et al, Am Heart J 2002;143:1017-26
  • 43. …and finally Until then… Do things because you should do them, not because you can!Or, alternatively… Just because you’ve got them, don’t let them cloud your clinical judgement. And keep them to yourself!
  • 44. THANK YOU!!

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