ΟΜΑΔΕΣ ΕΡΓΑΣΙΑΣ ΘΕΣ/ΝΙΚΗ 2013

Transcription

1 ΟΜΑΔΕΣ ΕΡΓΑΣΙΑΣ ΘΕΣ/ΝΙΚΗ 2013 ΘΡΟΜΒΟΑΝΑΡΟΦΗΣΗ ΣΤΟ STEMI ΕΝΔΕΙΞΕΙΣ - ΑΠΟΤΕΛΕΣΜΑΤΙΚΟΤΗΤΑ!. "#$%µ& ( # MD,Phd )#*+,-. )/ µ7µ# 8& µ9#+,- 7: "#$;,/(/<=#:

2 Δηλώνω κανένα οικονομικό όφελος από τις εταιρείες χορηγούς του συνεδρίου: ABBOTT LABORATORIES HELLAS ACTELION ASTRAZENECA BAYER HELLAS BOEHRINGER ELPEN GALENICA MENARINI HELLAS PFIZER HELLAS PLUSMEDICA SANOFI SPECIFAR ΦΑΡΜΑΣΕΡΒ ΛΙΛΛΥ WINMEDICA RAFARM GE HEALTHCARE NOVARTIS HELLAS MEDWORKS ΙΠΠΟΚΡΑΤΗΣ ΙΑΤΡΙΚΑ ΜHXANHMATA

3 Issues to be addressed 1. Thrombus presence is associated with adverse clinical outcome 2. Significance of microvascular obstruction after ppci 3. Mechanical aproaches to thrombus 4. Manual aspiration devices: clinical impact in STEMI 5. Tips and tricks 6. Conclusions

4

5 old fibrin-rich thrombi >70% fibrin <30%platelet (found in patients with an ischemic time of >3 h). fresh platelet-rich thrombi >30% platelet < 70% fibrin (found in patients presenting within the first hour following symptom onset)

6 Thrombus classification Grade&0:& &no&thrombus&present& Grade&1:& &possible&thrombus&present:&reduced& contrast&density,&haziness,&irregular&lesion&contour& Grade&2:& &thrombus&present,&small&size.&definite& thrombus&with&greatest&dimension&1/2&vessel&diameter&& Grade3:&& &thrombus&present,&moderate&size.&greatest& linear&dimension&>1/2&but&<&2&vessel&diameters&& Grade&4:& &thrombus&present,&large&size.&largest& dimension>&2&vessel&diameters&& Grade&5:& &unable&to&assess&thrombus&burden&due&to& total&vessel&occlusion&!!!!gibson!cm!et!al,!circula2on!2001!!

7

8 Visible thrombus correlates with: 1.Increased infarct size 2.More distal embolization 3.Decreased TIMI flow 4.Increased microvascular obstruction 5.Decreased Myokardial Blush Grade 6.Decreased ST-Segment resolution Larger Thrombus correlates with 1. Mortality 2. MACE Gibson!CM!et!al,!Circula2on!2001!!

9 Thrombus Burden and Infarct-Related Artery Stent Thrombosis after DES implantation in STEMI Sianos, et al JACC 2007; 50; Sianos, et al JACC 2007; 50;

10 Impact of Thrombus Burden on Mortality and MACE Sianos, et al JACC 2007; 50;

11

12 Reasons for suboptimal reperfusion results Distal Embolization Thrombus materials Atherosclerotic materials Tissue edema-cellular swelling Vasospasm Endothelial dysfunction Reperfusion injury Inflammation 15% of STEMI patients reactive O2 species Intracellular Ca overload Microvascular disruption

13

14

15 Distal Myocardial Protection Device

16 Distal protection device (quard wire) during ppci in STEMI-EMERALD study 501 pts distal protection device Complete ST Resolution control p value 63.3% 61.9% 0.78 LV infarct size 12% 9.5% 0.15 MACE 10% 11% 0.66 No reflow no difference

17

18

19 Rheolytic Thrombectomy (RT) With Percutaneous Coronary Intervention for Infarct Size Reduction in Acute Myocardial Infarction AIMI Study 480 pts Angio-jet group (240 pt) control group (240 pts) p value Infarct size 12,5%±12.1% 9.8±10.9% 0.03 TIMI flow III 91.8% 97% <0.02 Myocardial Blush Grade ST Resolution no difference no difference

20

21

22 X-Sizer for Trombectomy in STEMI AMINE trial 201 pts x-sizer group control group p value ST resolution 68% 53% Distal embolization 2% 10% TIMI III 96% 89% 0.1 MBG 3 30% 31% NS death (6 months) MACE (6 months) 6% 4% NS 13% 13% NS

23

24

25

26 Aspiration Thrombectomy Catheters Export XT Export 6F Expor t 7F Pronto V3 Diver (side holes) Quick Cat Fetch Xtract 6F Xtract 7F Soft, bevele d short tip Bevel cut Bevel cut Rounde d bullnose tip with slot cut to prox tip Bevel cut with long tip and 3 side holes Bevel cut with long tip Conve x cut Flat cut Flat cut Distal Lumen (inches)

27 Manual&Thrombectomy

28

29

30 TAPAS&Study Patient Flowchart Patients Enrolled n = 1071 Primary Aspiration n = 535 Randomized Conventional Stenting n = 536 Primary PCI: n=502 Aspiration then Direct Stenting: n=295 Aspiration then Dilatation: n=153 Crossover to Conventional Stenting: n=54 Primary PCI: n=503 Balloon dilation then direct stenting: n=485 Additional thrombus aspiration: n=12 Crossover to thrombus aspiration: n=6 MBG assessed: n=490 ST-segment assessed: n=486 MBG assessed: n=490 ST-segment assessed: n=486 Clinical 30 days: n=529 (530 at 1 year) Clinical 30 days: n=531 (530 at 1 year) Svilaas T. et al., NEJM, February 7, 2008

31

32

33 TAPAS&Study& &1&Year& death reinfarction death/reinfarction TVR MACE P = P = P = Patients (%) Thrombus aspiration Conventional PCI Statistically Significant Reduction in Death and Reinfarction in Favor of Export Group

34 TAPAS&Study& Conclusions Thrombus&aspiraNon&with&Export&AspiraNon&Catheter&in&STEMI& panents&results&in&improved!myocardial!reperfusion&and&clinical! outcome!as&compared&with&convennonal&pci,&irrespecnve&of& panents &clinical&and&angiographic&features&(i.e.&visible&thrombus& on&angiography).& Thrombus&aspiraNon&with&Export&AspiraNon&Catheter&results&in&a& lower!mortality&and&combined&mortality&and&nonwfatal& reinfarcnon&at&1&year.& Svilaas T. et al., NEJM, February 7, 2008

35

36 EXPIRA trial

37 EXPIRA TRIAL : S-PCI had a higher incidence of cardiac death (log-rank p = 0.02) than did Export- PCI

38

39

40

41

42

43

44 INFUSE-AMI: IC-ABCIX NO IC-ABCX INFARCT SIZE ASPIRATION NO-ASPIRATION THROMBUS PRE-STENTING 48.8% 66.9% TIMI 0/1 BEFORE STENTING MBG 0/1 BEFORE STENTING 13.6% 38.7% < % 40% <0.0001

45 Effects of Mechanical Thrombectomy and Intracoronary Abciximab on Coronary Flow and Infarct Size During Primary PCI: Analysis from the INFUSE-AMI Trial reduction in infarct size, as % of LV mass measured by MRI compared all other groups 14.7% vs. 17.6%, P=0.03. Only the combination of the 2 treatments resulted in smaller infarct size, suggesting both pharmacological and mechanical thrombus modification in STEMI may be required to improve outcomes. J Am Coll Cardiol. 2012;60

46 Tips in thrombus aspiration Gentle advansing the catheter (can easily kink) Keep quide deeply engaged (avoid systemic embolization) Start at the proximal end of thrombus then proceed distally Multiple attempts (according to angiographic result) Withdraw whole device under negative pressure if blocked during aspiration. Allow generous backflow after retrieving device

47

48

49

50

51

52

53

54

55

56

57 Primary PCI-Thrombus load: Grade 5 no aspiration device slow-reflow PCI Radiation total time : 18.0 min

58

59

60

61

62

63

64 Primary PCI-Thrombus load: Grade 5 aspiration device use NO no-reflow PCI Radiation total time : 11.3 min

65 Keep it simple User&friendly& No&delay,&no&extra&radiaNon&Nme,&no&prolonged&procedures& Operator&makes&2W3&or&more&passes&without&difficulty& Good&deliverability&due&to&hydrophilic&coaNng& so]&np& good&profile&0,068 & No&vessel&wall&irritaNon&(by&distal&balloon&or&basket,&large& profile&catheter&)& No&extreme&vacuum&forces& Operator&maneuvers&the&catheter&during&vacuum&

66 Summary Thrombus burden and size predicts no-reflow phenomenon Is an independent predictor of adverse outcome Angiographic visual embolization increases risk of impaired reperfusion predicts a poor outcome Thrombus aspiration improves myocardial reperfusion and may work in synergy with IIb-IIIa inh. or bivalirudin to improve both surrogate as well as clinical endpoints.

67 Taking home message Large or small thrombus burden Use manual thrombus aspiration No visible thrombus: Use thrombus aspiration at operator discretion and judgment