True Bifurcation LM Stenosis (Medina 1,1,1) With Very Extensive Calcification: CABG Or PCI?

Transcription

1 True Bifurcation LM Stenosis (Medina,,) With Very Extensive Calcification: CABG Or PCI? T. Santoso University of Indonesia Medical School, Medistra Hospital, Jakarta, Indonesia

2 PCI or CABG for Unprotected LM Stenosis: A Meta-Analysis of,77 Patients Study Year Mortality Brener Buszman Chieffo Makikallio Palmerini Sanmartin Seung SYNTAX_LM White Wu Summary Study Year MACCE Buszman Chieffo Makikallio Sanmartin Seung SYNTAX_LM White Summary Study Year TVR Buszman Chieffo Makikallio Sanmartin Seung SYNTAX_LM White Wu Summary PCI better CABG better PCI better CABG better PCI better CABG better No difference in mortality, MACCE for up to yrs, but higher risk of TVR Naik H. cs, J. Am. Coll. Cardiol. Intv. 009;; Naik H. cs, J. Am. Coll. Cardiol. Intv. 009;;79-747

3 Profile Of Case: Calcified LM Male, 75 yrs old with progressive angina at rest since one week Other illnesses: hypertension, Type II DM, chronic renal failure (on dialysis), COPD, history of left lower pulmonary lobectomy Underwent coronary angiography weeks ago, told to have high risk for PCI or surgery. PE: BP 80/9, otherwise unrevealing Lab: Hb 0.6 g/dl, ureum 80 mg/dl, creatinine.5 mg/dl, blood sugar 5 / 4 mg/dl, enzymes slightly elevated ECG: normal Chest film: mild cardiomegaly, no pulmonary congestion Echo: LVH, EF 75% Treatment on admittance: clopidogrel, aspirin, cilostazol, carvedilol, irbesartan, ISDN (IV drip), enoxaparin, short acting insulin (actrapid)

4 Coronary Angiogram Very tight LM ostial stenosis GC: 7F EBU, difficult to engage Damping of pressure every time GC was engaged (required GW insertion to avoid this) Fluoroscopy: massive calcification noted in LM & proximal mid LAD

5 Coronary Angiogram LM: short, with tight ostial stenosis 90% until bifurcation (Medina,,) LAD: diffuse 70 90% stenosis in the prox mid segments LCX: ostial 80% stenosis, then another 80% stenosis in the proximal segment RCA: 80% stenosis distally (not shown) SYNTAX SCORE : 9 EuroSCORE : 8 Parsonnet SCORE : 8 Clinical SYNTAX SCORE : 78 Global Risk Class: High

6 How Should We Treat This Patient?. PCI. CABG

7 Risk Assessment In Pts Undergoing Revascularisation With LM Is Of Paramount Importance Risk Assessment In Pts With LM Lesions Risk Model No. variables used to calculate score Clinical Angiographic PCI Validated in PCI/CABG CABG Specific evaluation in LM pts EuroSCORE Mayo Clinic Risk Score ACEF 0 + AHA/ACC Classification 0 (per lesion) + + SYNTAX 0 (per lesion) STS 40 + Clinical SYNTAX Score (per lesion) + + Global Risk Classification 7 (per lesion) NERS + +. Modified after Garg S, cs. JACC Intv 00;:89 90;. Chen SL, cs. JACC Intv 00;:6 4;. Capodanno D., et al. JACC Intv. 0;4;87 97

8 0d Operative Mortality Percent Clinical (Parsonnet & EuroSCORE) Scores Parsonnet Score EuroSCORE EuroSCORE Patients Died 0 (low risk) (0.8%) 5 (medium risk) (.0%) > 6 (high risk) (.%) Total (4.7%) Cumulative Event Rate (%) This patient has Parsonnet Score = 8 & EuroSCORE = 8 High risk for CABG Preoperative Risk Classification High SYNTAX Scores ( ) LM Subset CABG (N=66) P=0.004 TAXUS (N=55) 0 4 Angiographic Score (SYNTAX) Months Since Allocation.4% 7.9% 6 This patient has SYNTAX SCORE = 9 higher risk for PCI High score (>) LM disease (& Registry pts) are best treated with CABG at least in the short term ( years follow up) Nashef SAM, cs. Eur J Cardiothoracic Surg 999;6:9-; Parsonnet V, cs.circulation 989;79(suppl I):I--I-; Kappetein P, TCT 00

9 Combined Clinical (EuroSCORE) & Angiographic (SYNTAX) Scores: Global Risk Classification (GRC) EuroSCORE > 6 Low Low SYNTAX score < - > Low Low Intermediate Intermediate Intermediate Intermediate High Cardiac death free survival (%) Cardiac death free survival (%) P = 0.004* LOW MIDDLE HIGH P < 0.00* LOW MIDDLE HIGH 96.% 94.6% 78.% SYNTAX score 4 Time (months) GRC 98.4% 84.0% 68.6% 4 Time (months) GRC has the better predictive ability for both safety & efficacy endpoints This patient is in the high risk class both for PCI & CABG Capodanno et al, Am Heart J 00:59:0-9

10 Cumulative cardiac mortality rate (%) Combined Clinical & Angiographic Risk Scores: Clinical SYNTAX Score (CSS)* *CSS = SYNTAX Score x (age/ef + for each 0 ml the CrCl < 60 ml/min per.7 m) PCI Log-Rank P< Time (days) High CSS: 5.6% Low CSS:.6% Mid CSS:.0% Cumulative cardiac mortality rate (%) CABG Log-Rank P= Time (days) CSS of patient: 78 patient is in a high risk for PCI & CABG With a EuroSCORE of 8, SYNTAX Score of 9, Clinical SYNTAX Score of 78, High GRC the patient is clearly in a high risk for either PCI or CABG What would you do? CSS < 5.6 : low CSS 5.6-<7.5: mid CSS > 7.5: high High CSS: 9.% Low CSS:.9% Mid CSS:.7%. Garg S, cs. Circ Cardiovasc Interv 00;:7-6;. Capodanno D, cs. JACC Intv. 0;4;87-97

11 Clinical & Angiographic Characteristics Influencing The Choice Of Treatment Strategy In This Patient Favoring PCI: LM stenosis with high EuroSCORE & presented with acute coronary syndrome is associated with increased risk of death & MI -5 Elderly patient has lower risk of stroke with PCI compared to CABG Patient is already fully anticoagulated Even though the patient is a diabetic, in LM stenosis, aside of increased TVR, PCI results in similar rates of death, MI, stroke compared to CABG 6 Favoring CABG: Very diffuse multi-vessel disease with SYNTAX scores> may increase the likelihood of incomplete revascularization (which will lead to worse long term outcome) 7 Heavily calcified lesions are unsuitable for stenting 8 Left main plus tight RCA stenosis may increase the risk of PCI? Renal Dysfunction (HR= if Sr Cr> mg/dl).lee MS, et al.jacc 006;47:864 70;.Rodes Cabau J, et al. Circulation 008;8:74 8;. Tamburino C, et al. Am J Cardiol 009;0:87 9; 4. Kim YH, et al. Am J Cardiol 009;98:567 70; 5.Tamburino C, et al. Cathet Cardiovasc Interv 009;7:9 8; 6. Kim WJ, et al. JACC Interv 009;:956 6; 7. Capodano D. cs, JACC Intv. 009;;7 78; 8. Park SJ, et al. Circ Cardiovasc Intervent 009;:59 68

12 If you want to do PCI, how? Guiding Catheter (GC)?:. 6F. 7 F. 8F

13 If you want to do PCI, how? GC: good back up, 7 or 8F. Be careful not to induce ostial LM spasm or dissection Guide Wire (GW)?:. Single. Double (LAD / LCX)

14 If you want to do PCI, how? GC: good back up, 7 or 8F. Be careful not to induce ostial LM spasm or dissection GW: double (LAD / LCX) Balloon?:. Semicompliant balloon. High pressure balloon. Cutting balloon

15 If you want to do PCI, how? GC: good back up, 7 or 8F. Be careful not to induce ostial LM spasm or dissection GW: double (LAD / LCX) Balloon: high pressure balloon (compliant/semicompliant balloon may increase the chance of edge dissection, balloon rupture, or even vessel rupture). Cutting balloon difficult to introduce DES or BMS?:. DES. BMS

16 If you want to do PCI, how? GC: good back up, 7 or 8F. Be careful not to induce ostial LM spasm or dissection GW: double (LAD / LCX) Balloon: high pressure balloon (compliant/semicompliant balloon may increase the chance of edge dissection, balloon rupture, or even vessel rupture). Cutting balloon difficult to introduce DES: DES with minimal late loss, & bigger cell size if another DES needs to be implanted in the SB Is lesion preparation important?:. Yes. No

17 If you want to do PCI, how? GC: good back up, 7 or 8F. Be careful not to induce ostial LM spasm or dissection GW: double (LAD / LCX) Balloon: high pressure balloon (compliant/semicompliant balloon may increase the chance of edge dissection, balloon rupture, or even vessel rupture). Cutting balloon difficult to introduce DES: DES with minimal late loss, & bigger cell size if another DES needs to be implanted in the SB Lesion preparation important: rotablation Any adjunctive devices needed?. IVUS, FFR. IABP. All

18 If you want to do PCI, how? GC: good back up, 7 or 8F. Be careful not to induce ostial LM spasm or dissection GW: double (LAD / LCX) Balloon: high pressure balloon (compliant/semicompliant balloon may increase the chance of edge dissection, balloon rupture, or even vessel rupture). Cutting balloon difficult to introduce DES: DES with minimal late loss, & bigger cell size if another DES needs to be implanted in the SB Lesion preparation important: rotablation IVUS, FFR important: IVUS catheter may be difficult to introduce in the presence of heavy calcification No IABP

19 PCI Massive calcification & long segmental, severe stenosis in the proximal & mid LAD precluded the use of IVUS. After predilatation of the LM & LCX ostial lesions, proximal LCX stenosis was stented with good result

20 Note: the lines of calcifications along the LAD course. The long segmental LAD stenosis was very resistant to high pressure balloon dilatation (note: the dog boning effect)

21 Rotablation of the LM/LAD with.50 & subsequently.75 mm burrs (use of bigger burr was not possible as the GC size was 7F)

22 Successful placement of overlapping drug eluting stents BioMatrix TM in the proximal mid LAD

23 A DK Crush Technique () C C. After GW exchange, further dilatation of LM LCX stent B D A. LM LCX stenting (BioMatrix TM ) B. Balloon crushing of LM LCX stent D. Kissing balloon dilatation

24 DK Crush Technique () E F E. DES stent (NOBORI.5x4 mm) placement from LM ostium to proximal LAD (overlapping with previously implanted stent) F. Balloon was slightly withdrawn & inflated again with a higher pressure & to create the flaring effect in the LM ostium (to be followed by final kissing balloon dilatation)

25 What would you do?. Call a surgeon. Ask for an echo machine. Immediate fluoroscopy guided pericardiocentesis 4. Others Suddenly blood pressure dropped to below /9 mmhg & HR to 8 bpm. Patient became apneic. Patient was intubated & CPR was rapidly instituted. Adrenaline, dopamine & dobutamine were administered. Contrast injection demonstrated big perforation in the proximal LAD & cardiac tamponade.

26 Suddenly blood pressure dropped to below /9 mmhg & HR to 8 bpm. Patient became apneic. Patient was intubated & CPR was rapidly instituted. Adrenaline, dopamine & dobutamine were administered. Contrast injection demonstrated big perforation in the proximal LAD & cardiac tamponade. A balloon was introduced & inflated to temporarily seal the leakage.

27 While doing cardiac massage, fluoroscopy guided pericardial paracenthesis was rapidly performed. Subsequently covered stent (x6 mm) was implanted to seal the perforation. After 500 cc of pericardiocenthesis, blood pressure increased to 8/96 mmhg. IABP was not inserted. Repeat contrast injection confirmed complete sealing of perforation.

28 Gradually patient s condition improved. No protamine injection was given. Fluoroscopy showed no more contrast accumulation in the pericardial cavity. Blood pressure was stabile at 6/6 mmhg & spontaneous breathing was noted.

29 Patient survived!! On the third day, before pulling out of the drainage catheter, angiogram was repeated. This showed beautiful result with no residual stenosis, TIMI III flow, Gr myocardial blushing, & absence of perforation.

30 What would you do further?. CABG (as soon as possible). CABG (elective). Medical treatment

31 Medications Patient was put on triple antiplatelet therapy: Aspirin, clopidogrel and cilostazol At least for one year Other medications: carvedilol, irbesartan, oral nitrates, rosuvastatin, short acting insulin (actrapid) Chronic dialysis continued Patient died months later because of hemorrhagic stroke

32 Summary () Risk stratification is necessary to determine treatment strategy This elderly patient is at high surgical risk (high EuroSCORE & Parsonnet SCORE, high GRC), but also at high risk for PCI (high SYNTAX SCORE, high CSS, high GRC) As the patient presented with acute coronary syndrome, & was already anticoagulated, PCI was still considered a reasonable option However, the severe, extensive calcification and multiple & diffuse long lesion made it not very suitable for stenting. Patient has perforation during postdilatation (before final kissing balloon dilatation) which was successfully managed by fluoroscopy guided pericardiocentesis.

33 Summary () Lessons learned regarding the technique: Do not panic or give up Lesion preparation, especially in complex anatomy, is important. Calcification is a big enemy of interventionist. In case of extensive, severe calcification: For predilatation never use compliant balloon (. balloon may rupture,. dog boning effect at the proximal/distal end of balloon or balloon oversizing at full inflation may lead to dissection/perforation) Rotablation is helpful. Be reminded that LM & proximal LAD are big vessels. Use of burr >.00 mm may be necessary to achieve better debulking. For postdilatation also use appropriately sized high pressure (noncompliant) balloon If possible, use of IVUS is important Fluoroscopy guided pericardiocentesis is always faster than echoguided pericardiocentesis