Coronary interventions

Transcription

1 Controversial issues in the management of ischemic heart failure Coronary interventions Maciej Lesiak Department of Cardiology, University Hospital in Poznan

2 none DECLARATION OF CONFLICT OF INTEREST

3 CHF aetiology Randomized trials 13 randomized trials on CHF n=20198 n= % CAD 32% Non-CAD 64% CAD 36% Non-CAD Gheorgiade M. et all. Circulation 1988,97,202 Cleland JGF et all. Eur Heart J 2001,22,1601 Coronary artery disease is the underlying cause in approximately two thirds of patients with heart failure with

4 Diagnostic modalities in patients with HF & possible CAD

5 Indications for Coronary Angiography in Patients with Heart Failure Heart failure patients with angina Patients with prior myocardial infarction or known CAD Patients with a strong risk factor profile Patients with unexplained heart failure Patients with positive functional tests Heart failure patients with severely dyskinetic myocardium

6 What determines the risk of patients with HF and coronary atherosclerosis?

7 Impact of Ischemia on Risk of Cardiac Death 10, 627 patients having exercise or adenosine MPI Follow-up for years Inducible ischemia and severity of angina were independent predictors for death Hachamovitch et al. Circulation 2003;107:

8 Death or MI Rate (%) COURAGE Nuclear Substudy the risk of death / MI according to residual ischemia 40% p= ,3% 30% p= % p= ,6% 22,3% 10% 0% 0,0% 0% (n=23) 1%-4.9% (n=141) 5%-9.9% (n=88) >10% (n=62) Shaw LJ. et al. Circulation 2008;117:

9 COURAGE Nuclear Substudy Ischemia reduction reduces events 105 Patients with >10% Baseline Ischemia 83.8% 66% Rate of death/mi over 3.5 years was 16% among patients with significant ischemia reduction compared with 34% without Shaw LJ. et al. Circulation 2008;117:

10 COURAGE Nuclear Substudy PCI reduces ischemia better than OMT alone Shaw LJ. et al. Circulation 2008;117:

11 Revascularization Reduces the Risk of Cardiac Death 10, 627 patients having exercise or adenosine MPI Follow-up for years Hachamovitch et al. Circulation 2003;107:

12 log Hazard Ratio (Mortality) Log Hazard Ratio as a Function of Ischemic Myocardium 1 N=5366 F/U=2.8 yrs Cardiac death Medical Rx* Revascularization* % 25% 32.5% 50% *p<0.001 % of Total Myocardium Ischemic Hachamovitch et al. Circulation 2003;107:

13 Reducing ischemia reduces death and MI

14 Revascularization Efficacy Depends on the Degree of Ischemia at Baseline

15 Revascularization Efficacy Depends on the Degree of Ischemia at Baseline

16 Revascularization, by reducing ischemia reduces death and MI!!!

17 Stenosis Ischemia

18 Stenosis Ischemia 69 yo male, inferior MI 3 years before. Dyspnoea, fatigue, EF ~ 40% CTO of RCA Angiographicaly significant stenosis at the ostium of LCx

19 FAME study: Procedural Results (1) ANGIO-group N=496 FFR-group N=509 P-value # indicated lesions per patient 2.7 ± ± FFR results Lesions succesfully measured, No (%) (98%) - Lesions with FFR 0.80,No (%) (63%) - Lesions with FFR > 0.80,No (%) (37%) - stents per patient 2.7 ± ± 1.3 <0.001 Lesions succesfully stented (%) 92% 94% - DES, total, No N Engl J Med 2009; 360:

20 FAME study: Event-free Survival absolute difference in MACE-free survival p=0.02 FFR-guided Angio-guided 30 days 2.9% 90 days 3.8% 180 days 4.9% 360 days 5.3% N Engl J Med 2009; 360:

21 MR Transmural necrosis (>75%) & hypoperfusion

22 Left Ventricular Function After Percutaneous Recanalization of Chronic Total Coronary Occlusions SWT before stenting SWT 5 months after stenting SWT 3 years after stenting Kirschbaum,et al. Am J Cardiol 2008;101:

23 Impact of Revascularization on Prognosis in Pts With CAD and LV Dysfunction: a meta-analysis 3088 patients, mean EF 32 ± 8% FU 25 ± 10 months Allman KC et al. JACC 2002;39:1151 8

24 Impact of Revascularization on Prognosis in Pts With CAD and LV Dysfunction: a meta-analysis left ventricular EF and predicted change in mortality for patients with viable versus nonviable myocardium Left ventricular EF in % Allman KC et al. JACC 2002;39:1151 8

25 Stenosis Ischemia Revascularization will not help and may be harmful! Little/no viable myocardium Stenosis functionally not significant

26 What revascularization? PCI? CABG?

27 Risk stratification scores

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30 3 Vessel Disease

31 SYNTAX Score 11

32 3 Vessel Disease

33 SYNTAX Score = 52

34 Patients with CHF and left ventricular EF 35%, predominantly with anginal symptoms SVR surgical ventricular reconstruction

35 Patients with CHF and left ventricular EF 35%, predominantly with HF symptoms

36 69 YO man, admitted for heart failure NYHA class IV Severe aortic stenosis, VA ~ 0,6 cm 2 previous anterior MI, current left ventricular EF 25% Stroke 2x (mild disability), IDDM, CKD (egfr 40 ml/min/1.73 m 2 ) EuroSCORE 11 (28%)

37 69 YO man, admitted for heart failure NYHA class IV Severe aortic stenosis, VA ~ 0,6 cm 2 previous anterior MI, current left ventricular EF 25% Stroke 2x (mild disability), IDDM, CKD (egfr 40 ml/min/1.73 m 2 ) EuroSCORE 11 (28%) Critical distal LM stenosis Significant mid RCA stenosis

38 PCI LM stenting with 3.5x28 DES Kissing balloon post dilatation

39 LAD dissection LAD stenting with 3.0x23 DES

40 Acute result after LM/LAD stenting Acute result after RCA stenting

41 After 3 months patient s clinical status improved substantially NYHA class II/III ECHO: left ventricular EF increased to 35% Before PCI EF = 25% After 3 months EF = 35%

42 Control angiography six months after PCI (before TAVI) LCA RCA

43 Aortic angiography before TAVI (mild AR)

44 Aortic angiography after CoreValve implantation Fife months after TAVI patient is alive in NYHA class II heart failure

45 Take-home message Coronary artery disease is the underlying cause in approximately two thirds of patients with heart failure with depressed systolic function Angina is a simple predictor of ischemia, but heart failure patients are often asymptomatic with regard to ischemic symptoms (dyspnoea may be the leading symptom) Ischemia is an independent predictor of death / MI in HF patients

46 Take-home message (cont.) Assessment of myocardial viability is of utmost importance to detect ischemic but viable myocardium for potential coronary interventions Revascularization (PCI/CABG) is the best method to decreased the risk of death in HF patients with persistent myocardial ischemia. In CABG patients the benefits of coronary artery revascularization need to be balanced against the risks of surgery, which can be substantial in the presence of severe HF

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