9630942363 Genuine Call Girls In Ahmedabad Gujarat Call Girls Service
Ppci culprit vs mv acad card 2013 mumbai
1. Primary Percutaneous
Coronary 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
9. PPCI-culprit VS MV VS staged
THREE STRATEGIES
1)CULPRIT ONLY: PCI confined to culprit vessel
only
2)MV-PCI: all interventions during same
procedure
3)STAGED PCI:PPCI of culprit vessel during index
procedure.
Non culprit PCI subsequently
10. Culprit Vessel Only Versus Multivessel
and Staged Percutaneous Coronary
Intervention 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 STEMI
Flow diagram of study •4 No stratification to at least 2 of
inclusion and exclusion. the 3 PCI strategies
PCI = percutaneous coronary •1 Comparing complete vs.
intervention;
incomplete revascularization
STEMI = ST-segment
•1 Comparing 2 strategies for
elevation myocardial
infarction. 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 0.42
J Am Coll Cardiol. 2011;58(7):692-703. Total events 356 164
13. Prognostic Impact of Staged
Versus “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-A
3602 pts with STEMI with symptom onset <= 12 hours
Randomized into UFH +/- GP II b/III a inhibitor vs. Bivalirudin
monotherapy (+/- 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 strategy
Single/ 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 AMI
Single/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’ MV
Single/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
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 P
GP IIb/IIIa 59.5% 62% NS
Stenting of IRA 70.9% 45.6% <0.001
Core Lab analysis N=58 N=63
Final 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
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
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
42. Staged vs non-staged procedures in multivessel PCI
(predominantly non-emergency)
Staged (n=135) Nonstaged (n=129) P
In-hospital 3 (2.2%) 6 (4.6%) 0.28
MACE
1-yr outcome
Q MI 1 (0.7%) 5 (3.9%) 0.09
TLR 23 (17.2%) 28 (21.9%) 0.34
MACE* 35 (26.1%) 46 (35.9%) 0.08
Total 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!
