Non merci! Revascularisation complète à la phase aigue de l infarctus? 8 e Cardiorun, La Réunion, 1 er octobre Gilles Rioufol, MD, PhD

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1 Revascularisation complète à la phase aigue de l infarctus? Non merci! 8 e Cardiorun, La Réunion, 1 er octobre 2014 Gilles Rioufol, MD, PhD Interventional cardiology dpt Cardiovascular Hospital - Lyon - France INSERM U1060

2 Meta-analysis for multi-vessel PCI during acute STEMI : is the answer already known? Short term mortality 4 randomized trials 14 registries Short term mortality Favour culprit only-pci Favour MV-PCI Zhang et al. PLoS One 2014;9:e92316

3 multi-vessel PCI during acute STEMI : is PRAMI the answer? n=465 STEMI 2/3 2-vx disease %DS>50% 9% Culprit only PPCI vs all stenosis liberal PCI during PPCI 23% Duration 63 vs 45 min*** Contrast 300 vs 200 ml *** Wald et al. NEJM 2013;369:1115

4 multi-vessel PCI during acute STEMI : is CvLPRIT the ultimate confirmation? n=296 STEMI 2/3 2-vx disease %DS>70% 21% Culprit only PPCI vs all stenosis liberal PCI during PPCI 10% MACE= death+mi+chf+revasc Gershlick et al. ESC 2014

5 Revascularisation complète à la phase aigue de l infarctus? Thank Non you merci Christophe!! 8 e Cardiorun, La Réunion, 1 er octobre 2014 Gilles Rioufol, MD, PhD Interventional cardiology dpt Cardiovascular Hospital - Lyon - France INSERM U1060

6 PRAMI and CvLPRIT: unsolved questions left behind How non culprit lesions could lead to MACEs so frequent, so early, with only mild stenosis? Oldroyd. EuroPCR 2014 Gershlick et al. ESC 2014 Wald et al. NEJM 2013;369:1115

7 Current knowledge for non culprit lesions in ACS (I): PROSPECT legacy Median to event no rapid prog # 7 months (223d) rapid prog # 13 months (401d) 92% UA /o progressive A 8% Death /o MI 6.5% 4% 3% non culprit lesion MACEs are not so frequent not so severe Stone et al. NEJM 2011;364:226

8 Current knowledge for non culprit lesions in ACS (II): Angio appearence The case of complex lesion 60 single CP MCP ** * *** *** *** The case of angio variability April 27 th June 12 th 59 paired-ncl >50%DS median 73d 21% patients show <50%DS (49±14% to 40±17% ***) non culprit lesion are significantly overestimated at the moment of PPCI Hanratty et al. JACC 2002;40:911 Goldstein et al. NEJM 2000;343:915

9 Non culprit lesions in ACS: accelerated atherosclerosis or plaque regression? non infarct related coronary IBIS 4: non infarct related coronary 10/10 Apoe -/- mice 74% patients show disease regression in at least one artery 54% patients show disease regression in both arteries Räber et al. Eur heart J 2014, in press Dutta et al. Nature 2012;487:325

10 Complete revascularization during acute phase of STEMI: when? Bainey et al. Am Heart J 2014;167:1

11 Angiography and functional significance by FFR (I) %DS 50% and FFR>0.80 = mismatch 35% non left main n= % 16% Se = 61% Sp = 67% Acc = 64% Toth et al. JACC 2014; in press %DS<50% and FFR 0.80 = mismatch Park et al. JACC Cardiovasc Intv 2012;5:1029

12 Angiography and functional significance by FFR (II) FAME Study 1.0 FAMOUS-NSTEMI study 1329 lesions 704 lesions Angio (and operator) poorly discriminate functionnally significant lesion 213 lesions Hamilos et al. circulation 2009;120:1505 Layland et al. Eur Heart J 2014; in press Tonino et al. JACC 2010;55:2816

13 Could FFR be the accurate tool for non culprit lesion during PPCI? (I) 101 pts 75% STEMI stenosis 56±14% FFR repeated 35±4d Kern et al. Circulation 2006;114:1321 Ntalianis et al. JACC Intv 2010;3:1274

14 Could FFR be the accurate tool for non culprit lesion during PPCI? (II) ongoing trials n Immediate PCI strategy Non culprit strategy FFR non culprit strategy COMPARE- ACUTE 800 Culprit only vs complete FFR guided COMPLETE 3000 Culprit only in both groups PRIMULTI 650 Culprit only in both groups Guideline-based Staged guideline vs FFR based Staged within index admission FFR all lesion>50% (blinded for culprit group) FFR if lesion 50-70% PCI si > 70%DS FFRif lesion 50-90% PCI si > 90%DS

15 conclusions At the acute phase of STEMI: - Qualitative angio (ie complex plaque) should not be forgotten - Angio is poorly accurate for no culprit ischemia assessment - When PPCI, non culprit plaque appearence isn t fixed - Except a dogmatic strategy for full-metal coverage, to date: no robust data support an angio-based all lesion stenting no robust data support systematic non culprit stenting during PPCI - The place of FFR in acute phase of STEMI is under evaluation - The timing for staged FFR-guided PCI is under evaluation