Georgios Pavlakis. Consultant Interventional Cardiologist. K.A.T. General Hospital of Athens, GREECE

Transcription

1 Georgios Pavlakis Consultant Interventional Cardiologist K.A.T. General Hospital of Athens, GREECE

2 Male patient, 72 years-old was admitted because of STEMI of the Inferior wall. Pre-cathlab ECG : ST Elevation in Inferior leads II, III, VF, Sinus rhythm 60 bpm. Onset of continuous chest pain: About four hours before admission. Previous STEMI with PCI in LAD and PCI in LCX (2005) because of sub-total stenosis. (2X Cypher stents). Risk factors: Heavy smoker, hypertension, diabetes (insulin), dyslipidemia. At admission, before urgent Angiogram: Aspirin 500 mg, clopidogrel600mg (PO) were given. Heparin 5000 IU was given intravenously. At Cath Lab: Persistence of ST elevations in ECG, but gradual relief of chest pain. Blood pressure - 110/70 mmhg

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5 A decision was made to delay the angioplasty and/or stent implantation in RCA for a few days. Medical Therapy : Tirofiban hydrochloride intravenously. 0,15 μgr/kg/min Enoxaparin 60 mg BD SC. Dual oral antiplatelet therapy : Aspirin 100 mg OD PO and Prasugrel 10 mg OD PO after loading with 60mg Patient remained pain free and hemodynamically stable during the hospitalization - Gradual reduction of hs-tni blood levels after day 2. A repeat angiogram was performed in day 4 after admission ( Transradial interventions were performed ).

6 2nd Angiogram -Improvement : No visible thrombus in RCA, distally to the stenosis. TIMI- III flow. One DES implantation in proximal RCA. (Promus Prime 4.0 X 20 mm) Successful stent placement. No Thrombus distally to the implanted stent. Shortly afterwards, onset of mild chest pain, gradually increasing. ECG : ST Elevation in leads II, III, VF. Sinus bradycardia, 45 beats/ min. No drop in blood pressure

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8 IC Nitrates were given two times and a bolus of 100 μg of IC epinephrine. 4 minutes later, coronary flow improved and we decided to wait for about 10 minutes in total. Patient soon became pain-free. IV Tirofiban was given for extra 24 hours. Echocardiography showed hypokinesis of the inferior wall. Left ventricular ejection fraction was ~45%. Troponin (hs) levels: 1 st day > pg /ml with no late peak and at the day of discharge TNI < 1000 pg /ml Discharge from the hospital 4 days following PCI. Uncomplicated in-hospital course. The patient remains asymptomatic and at good functional status 6 months later.

9 Drugs that seem to be effective in the prevention or treatment of no reflow : adenosine, nitroprusside, verapamil, nicorandil, nitrates, dipyridamole, epinephrine.

10 Persistent No-Reflow Predicts Mortality in PCI No reflow has a reported prevalence of ~30% in patients who undergo primary PCI and can lead to an adverse clinical outcome, including heart failure, cardiogenic shock, sudden cardiac death and other major cardiovascular complications. Australian Registry ( ~ pts). Landmark analysis Kaplan-Meier survival estimates at < 30 days - showing the greatest mortality in those with persistent no-reflow. This outcome was the same during a median long-term follow- up period of five years. No reflow was an independent predictor of cardiac death over 5 years. EuroIntervention 2018;14: Papapostolou S, et al. Long-term clinical outcomes of transient and persistent no-reflow following percutaneous coronary intervention (PCI): a multicentre Australian registry

11 Thrombus Score Definition No angiographic evidence of thrombotic material Possible thrombus, appearing as a convex, hazy lesion with irregular contours at the site of total occlusion Definite thrombus 1/2 the vessel diameter Definite thrombus > 1/2 but < 2 vessel diameter Definite thrombus 2 vessel diameter Inability to assess thrombus burden assessment, even after guidewire passage A large thrombotic burden at angiography ( Grade 4,5 ), was found 1 to be an independent predictor for 2-year mortality and MACE rate in PPCI vs Thrombus Grade 3

12 Ectatic vessels with long lesions and a large thrombotic burden in patients with STEMI, predispose to no or slow-reflow phenomenon (NRP) during Primary PCI (PPCI). During PPCI, balloon passing the intracoronary lesion with balloon dilatation and stent implantation, may cause thrombus embolization, release of vasoconstrictive substances into the blood resulting in NRP. In patients with an acceptable coronary blood flow at emergency angiography (TIMI flow >I, as in our case), one option is to defer stenting for a few days with additional time being given for intensive pharmacological therapy to resolve or reduce the thrombus burden. In our patient no-reflow after stenting could not be avoided even with this strategy, but the improvement of coronary flow was fast, possibly due to the preparation for stenting of the vessel with pharmacological therapy that was given for three days. Thrombus (visible) was eliminated, potentially improving coronary flow when the second procedure was performed. The PCI was kept simple and only one relatively short stent was implanted.

13 CHANGE OF CULPRIT ARTERY BLOOD FLOW (TIMI) BETWEEN 1 ST AND 2 ND INTERVENTION EuroIntervention 2017;13: published online February 2017 At least seven days delayed stenting using minimalist immediate mechanical intervention (MIMI) in ST-segment elevation myocardial infarction: the SUPER-MIMI study

14 Theoretical Advantages of the deferred-stenting strategy (in selected patients) : Reduction of the thrombus burden and microvascular obstruction, It allows for a better sizing of the lesion and of the artery, leading to an optimized stent selection, Avoidance of unnecessary stenting or implantation of a shorter stent when the residual stenosis is not deemed significant during the second intervention (no thrombus, no spasm). Possible long-term benefit from the improvement of LV function from deferral strategy in selected pts and reduction of the need for repeat hospitalization for heart failure. Disadvantages of the deferred-stenting strategy Cost of prolonged hospitalization Risk of re-occlusion and new STEMI, between 1 st -Coronary angiography and the 2 nd Intervention PCI Risk of bleeding from intensive antiplatelet therapy. No benefit in hard endpoints (MACE or mortality) in up-to-date trials. 2-5

15 DEFER STEMI 2 is a RCT that showed reduction of no or slow-flow and increase of Myocardial salvage index at six months (MRI index), in patients with STEMI with deferral of stenting in selected patients : Age > 65 years old Heavy thrombus burden Lesion length > 25mm Three other RCTs were: DANAMI -3 DEFER and INNOVATION 3,4 with unselected STEMI patients and MIMIstudy 4 in which patients with grade >3 thrombus were actually excluded from randomization. Evidence is not enough: Few randomized trials. Heterogeneous population, different timing of the second intervention (from 16h up to 8 days following the first Angiography), difference in use of aspiration thrombectomy in the first intervention and in use of GP IIb- IIIainhibitors between the two interventions. In a recent meta-analysis (2017) 6 improvement of No-reflow and a statistically significant improvement in long-term LV function with the Deferred Stenting strategy was shown. No difference in MACE, mortality and bleeding was found between the two strategies in this meta-analysis.

16 A marked benefit of delayed stenting in Cardiac MRI indices : Myocardial salvage (percentage of left ventricular mass) and salvage index at 6 months: Muscle Salvage was greater in the deferred stenting group. Cardiac MRI performed at day 2 and at 6 months following PCI of the culprit vessel. Carrick D, Oldroyd KG, McEntegart M, et al. A randomized trial of deferred stenting versus immediate stenting to prevent no- or slow-reflow in acute ST-segment elevation myocardial infarction (DEFER-STEMI). J Am Coll Cardiol 2014;63:

17 A marked benefit of delayed stenting in patients with long lesions: When an implanted stent is longer than 24 mm. Lønborg J, Engstrøm T, Ahtarovski KA, et al., for the DANAMI-3 Investigators. Myocardial damage in patients with deferred stenting after STEMI: a DANAMI-3 DEFER substudy. J Am Coll Cardiol 2017;69:

18 Deferred stent implantation in selected patients with STEMI, may allow time for reduction of coronary thrombus burden and recovery of microvascular function, so that the risk of no-reflow during the second intervention is reduced. Early identification of STEMI patients at risk of no-reflow, before implanting a stent, is important. Multipleindiceshavebeentested. 7, 8 A simple index during the first angiography after initial restoration of epicardial flow, that can predict no-reflow phenomenon after stenting, remains to be clarified. The length of the coronary lesion and The grade of thrombus > 3 at presentation angiography, seem promising and should be further tested in adequately powered clinical trials of selected STEMI patients treated with a strategy of immediate versus delayed coronary stenting and its effect in long-term LV function and clinical outcome. References. 1. Sianos G., Papafaklis MI., Serruys PW. Angiographic thrombus burden classification in patients with ST- segment elevation myocardial infarction treated with percutaneous coronary intervention. J Invasive Cardiol. 2010;22: Carrick D, Oldroyd K, McEntegart M, et al. (DEFER-STEMI). A randomized trial of deferred stenting versus immediate stenting to prevent no- reflow in acute ST-segment elevation myocardial infarction J Am Coll Cardiol 2014;63(20): Kelbaek H, Hofsten DE, Kober L, et al. DANAMI 3-DEFER: an open-label, randomized controlled trial. Lancet 2016;387(10034): Kim L, Lee J, Yu C et al. INNOVATION Study. Circ Cardiovasc Interv. 2016;9:e Belle L, Motreff P, Mangin L, et al. the MIMI Study. Circ Cardiovasc Interv. 2016;9:e Qiao J, Pan L, Zhang B et al. Deferred Versus Immediate Stenting in Patients With STEMI: A Systematic Review and Meta-Analysis. J Am Heart Assoc ; 6(3): 7. Schram HCF, Hemradj V, Hermanides R, et al. Coronary artery ectasia, an independent predictor of no-reflow after primary PCI for STEMI. Int J Cardiol ;265: Bairangee A, Collison D, Oldroyd K. Resistance to flow in the coronary microcirculation: we can measure it. EuroIntervention 2017;13:

19 GEORGE PAVLAKIS

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21 PERCENT CHANGE OF CULPRIT ARTERY STENOSIS BETWEEN 1 ST AND 2 ND INTERVENTION EuroIntervention 2017;13: published online February 2017 At least seven days delayed stenting using minimalist immediate mechanical intervention (MIMI) in ST-segment elevation myocardial infarction: the SUPER-MIMI study

22 TREATMENT OF NO -REFLOW

23 Indices of Coronary Physiology FFR CFR IMR IMR corrected Formula Pd/ Pa (during hyperemia) mtt baseline / mtt hyperemia Pd x mtt(during hyperemia) Pa x mttx (Pd-Pw)/(Pa-Pw) (during hyperemia) (Pd: mean distal pressure; Pa: mean aortic pressure; mtt baseline: mean transit time at baseline; mtt hyperemia: mean transit time after hyperemia; Pw: coronary wedge pressure) IMR: whenτιμι ΙΙ flow in culprit vessel - before Stent implantation

24 ΑΤΙ score : Age, Thrombus burden, IMR FOLLOW UP 6 Months cmri ATI 0-1 : LOW RISK ATI 2-3 : INTERMEDIATE RISK ATI >3: HIGH RISK INDEX GRADE AGE> 50 1 IMR(pre-stent) IMR (pre-stent) > THROMBUSSCORE : 4 1 THROMBUS SCORE : 5 2

25 ΑΤΙ SCORE > 4 : Delay stenting! ΑΤΙ SCORE could predict the final infarct % change and size as assessed with cardiac MRI. BajrangeeA, Collison D, OldroydKG. Resistance to flow in the coronary microcirculation -we can measure it but what does it mean? EuroIntervention ;13(8):

26 Study using IMR measurement prestenting to assess the risk of no-reflow. According to the relation described in the graph, less than 35 mm of stent length should be considered when a 3.5 mm diameter stent is required, unless alternative/additional therapeutic strategies are planned upfront. De Maria GL, CuculiF, Patel N, et al. How does coronary stent implantation impact on the status of the microcirculation during primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction? Eur Heart J. 2015;36: