PCI Update Qesaria 2009

Transcription

1 PCI Update Qesaria 2009 Amit Segev Interventional Cardiology Chaim

2 Outline Primary PCI Non-ST elevation ACS Multi-vessel disease Hemodynamic assessment of borderline lesions - FFR Stable AP Non-coronary interventions - TAVI

3 23 Randomized Studies of Primary PCI vs. Lysis n=7739 Keeley et at, Lancet 2003

4 The RIKS The RIKS-HIA Registry Consecutive pts admitted in 75 of 78 hospitals with CCUs in Sweden Stenestrand U et al. JAMA 2006

5 The RIKS-HIA Registry Stenestrand U et al. JAMA 2006

6 The RIKS-HIA Registry Stenestrand U et al. JAMA 2006

7 How Late After Symptom Onset Does Opening the Infarct Related Artery Still Provide Benefit?

8 Survival of Myocardium Fraction of ischemic cells already dead Hours of Ischemia

9 BRAVE II : Efficacy of Late Primary PCI Schomig A et al. JAMA 2005

10 BRAVE 2 Infarct Size at 7 days Schomig A et al. JAMA 2005

11 BRAVE 2 30 day End-points Schomig A et al. JAMA 2005

12 What is the optimal device / drug for primary PCI?

13 9 DES vs. BMS RCTs in AMI (N=3,728 patients) Stone G. Fellows Course 2008

14 7 DES vs. BMS RCTs in AMI (n=2,357) TLR at 8 12 Months Pasceri V et al. AHJ 2007

15 7 DES vs. BMS RCTs in AMI (n=2,357) Stent Thrombosis at 8 12 Months Pasceri V et al. AHJ 2007

16 The Spanish ESTROFA Registry 23,500 pts treated w/des at 20 Spanish hospitals from ; 63% PES, 37% SES. Dual antiplatelet Rx for 8±3 months. 1.3% ST rate at median FU 22 (11, 32) mos ; 2.0% ST at 3 yrs De la Torre Hernandez J et al. JACC 2008

17 The Spanish ESTROFA Registry Multivariate Predictors of Stent Thrombosis (n=14,120) De la Torre Hernandez J et al. JACC 2008

18 The Spanish ESTROFA Registry Multivariate Predictors of Stent Thrombosis (n=14,120) De la Torre Hernandez J et al. JACC 2008

19 Is thrombus retrieval useful during primary PCI? Distal Protection and Thrombectomy in AMI - Macroscopic embolic debris can be retrieved from >75% of cases

20 Myocardial Blush-3 Flow: 15 RCTs De Luca G et al. AHJ 2007

21 Mortality at 30 Days: 18 RCTs De Luca G et al. AHJ 2007

22 TAPAS: 1,071 pts with STEMI undergoing primary PCI at a single center were randomized in the ER to manual aspiration (Export) vs. control Svilaas T et al. N Engl J Med 2008

23 TAPAS: 1,071 pts with STEMI undergoing primary PCI at a single center were randomized in the ER to manual aspiration (Export) vs. control Svilaas T et al. N Engl J Med 2008

24 What is the Optimal anti- Thrombotic Regimen in Primary PCI?

25 Abciximab in Primary PCI Meta-analysis 8 RCTs 3,949 pts with AMI w/i 12 undergoing primary (7) or rescue (1) PCI rand to abciximab vs. placebo De Luca G et al. JAMA 2005

26 HORIZONS-AMI Stone G et al. N Engl J Med 2008

27 HORIZONS-AMI Primary End-points Stone G et al. N Engl J Med 2008

28 HORIZONS-AMI Major bleeding (non-cabg) Stone G et al. N Engl J Med 2008

29 HORIZONS-AMI Mortality Stone G et al. N Engl J Med 2008

30 HORIZONS-AMI Stent Thrombosis Stone G et al. N Engl J Med 2008

31 Clinical events in the HORIZONS-AMI pharmacology arm at two years End point Bivalirudin, n=1800 (%) Heparin plus GP IIb/IIIa inhibitor, n=1802 (%) Hazard ratio (95% CI) Major bleeding, non-cabg All-cause mortality Cardiac mortality ( ) ( ) ( ) Reinfarction ( ) ARC definite or probable stent thrombosis ( ) Stone G. TCT 2009; September 21-25, 2009; San Francisco, CA.

32 Clinical and safety events in the HORIZONS-AMI stent arm at two years End point Taxus, n=2257 (%) Express baremetal stent, n=749 (%) Hazard ratio (95% CI) Ischemic target lesion revascularization MACE (death, reinfarction, stroke, stent thrombosis) ( ) ( ) All-cause mortality ( ) ARC definite or probable stent thrombosis ( ) Stone G. TCT 2009; September 21-25, 2009; San Francisco, CA.

33 NSTE-ACS

34 A case of ACS 76 year old woman presents to ER with shoulder discomfort Chronic risk factors: hyperlipidemia,, type II diabetes, HTN, chronic renal insufficiency Left shoulder pain improved with movement, massage therapy. Similar symptoms on exercise bike, resolves after 10 minutes Exam: HR 90, BP 118/70; crackles at both lung bases Labs: creatinine 1.7 mg/dl dl,, Troponin T 0.32

35 A case of ACS

36 According to GRACE score, what is her in-hospital and 6-month 6 mortality rate? 2-3% and 5% 5% and 9% 10% and 15% 20% and 30%

37 GRACE Score

38 GRACE Score

39 Selection of Initial Treatment Strategy: Invasive Versus Conservative Strategy UA/NSTEMI ACC/AHA guidelines. Circulation 2007

40 Non STE ACS Early Versus Invasive What s s new?

41 Randomized Trials in NonSTMI: Relative reduction in composite outcome and absolute difference in mortality Bogarty et al. Lancet 2003

42 Early Invasive vs Selective Invasive Meta-analysis, average 2 year follow-up Bavry et al. JACC 2006

43 ICTUS 4 year follow-up Lancet 2007

44 ICTUS Revascularization Lancet 2007

45 Bivalirudin

46 ACUITY Study 13,809 pts with mod-high risk ACS undergoing early invasive therapy Heparin + GPIIb/IIIa Bivalirudin + GPIIb/IIIa Bivalirudin alone Stone G et al. N Engl J Med 2006

47 ACUITY: 30 day outcome Stone G et al. N Engl J Med 2006

48 ACUITY - 30 day outcome

49 Acuity - Subgroup analysis Stone G et al. N Engl J Med 2006

50 ACUITY - Subgroup analysis Stone G et al. N Engl J Med 2006

51 Multi-Vessel Disease

52 SYNTAX Score

53 SYNTAX Trial Serruys PW et al. N Engl J Med 2009

54 SYNTAX Trial Serruys PW et al. N Engl J Med 2009

55 SYNTAX Trial Serruys PW et al. N Engl J Med 2009

56 SYNTAX Trial Serruys PW et al. N Engl J Med 2009

57 SYNTAX 12 Mo. Death / CVA / MI in LM Subset CABG TAXUS LM all (n=705) LM only (n=91) LM+1VD (n=138) LM+2VD (n=218) LM+3VD (n=258)

58 The Revival of FFR

59 FAME Study Primary EP - Composite of death, myocardial infarction, or repeat revascularization ( MACE ) at 1 year Tonino P et al. N Engl J Med 2009

60 FAME Study Tonino P et al. N Engl J Med 2009

61 FAME Study Tonino P et al. N Engl J Med 2009

62 FAME Study Tonino P et al. N Engl J Med 2009

63 SYNTAX Vs. FAME

64 PCI in Stable Angina

65 COURAGE Patients Screening COURAGE Trial. N Engl J Med 2007

66 COURAGE Nuclear Substudy COURAGE Trial. Circulation 2008

67 COURAGE Outcome by residual ischemia COURAGE Trial. Circulation 2008

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70 Patients with Obstructive Coronary Artery Disease, According to Noninvasive Test Result

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72 Trans-Catheter Aortic Valve Implantation (TAVI) Edwards Trans-femoral Trans-apical CoreValve Trans-femoral

73 High Risk AS Patients Octogenarians with multiple co-morbidities COPD Diabetes PVD Reduced LVEF Renal failure Previous cardiac surgery Euroscore >20% (~10% days) STS >10%

74 Inoperable AS Patients Radiation chest wall / heart disease Severe chest wall deformities End-stage COPD Cirrhosis with portal hypertension Porcelain aorta (CT proven) Degenerative neurocognitive dysfunction High frailty index (qualitative assessment) >50% chance of mortality or never leaving a chronic care facility Surgeons are gatekeepers!!!

75 At least 30% of severe AS pts. are untreated

76 First Generation Devices Edwards >2500 patients CoreValve >2500 patients

77 Pre-procedural Assessment Clinical cardiologist and surgeon Echocardiography Measurements Confirmatory TEE if necessary Angiography Do any PCI before Aortic injection Iliac / femoral angiography CTA if needed Any PCI should be done before!

78 Deployment of ProStar Closure Device Over 9Fr sheath

79 Balloon Valvuloplasty During rapid pacing (170/min) Extra-stiff guide-wire

80 Positioning of CoreValve Line #2 at annulus

81 Opening of Ventricular Segment of CoreValve

82 Opening of Aortic Segment of CoreValve - still retrievable!!

83 CoreValve Fully Deployed Mild AR

84 PARTNER Study

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86 OUTCOMES

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90 תודה ובה צלח הה!