Percutaneous Coronary Interventions Without On-site Cardiac Surgery

Transcription

1 Percutaneous Coronary Interventions Without On-site Cardiac Surgery Hassan Al Zammar, MD,FESC Consultant & Interventional Cardiologist Head of Cardiology Department European Gaza Hospital Palestine

2 European Gaza Hospital

3 BACKGROUND

4 GAZA STRIP PALESTINE WEST BANK Narrow zone of land, bordered by Egypt from South, Mediterranean Sea form West It is 46 km long and 5-12 km wide with an area of 362 square Km The Gaza strip is administratively divided into 5 governorates: North, Gaza, Mid zone Khan Yonis, and Rafah. It has 4 towns, 14 villages and 8 refugees camps. Lies west to Jordan River and the Dead Sea. It covers 5800 square km. The West Bank is divided into 10 governorates : Jerusalem,Jenin,Tulkarem, Qalqiliah,Nablus,Ramallah, Salfit,Bethlehem,Jericho andhebron. It has 10 towns, 430 villages and 18 refugees camps. About 150,000 Israelis live in West Bank scattered in numerous settlements.

5 POPULATION SIZE AND STRUCTURE The estimated number of Palestinian population all over the world by the mid of 2002 is 9,209,773. In Palestinian territories 3,464,550 (37.6%). In West Bank, 2,202,641 (63.6%) of total population in Palestine and (23.9%) from the total Palestinian population. In Gaza Strip, 1,261,909 (36.4%) of total population in Palestine and (13.7%) from the total Palestinian population so it represents one of the most densely populated areas in the world.

6 Leading Causes of Death in West Bank & Gaza Infectious Diseases %4 Renal Failure %5 Diabetes Mellitus %7 Septicaemia %4 Hypertensive Disease %4 Heart Diseases %33 Transport Accident %2 Pneumonia & Others Respiratory Disorders %11 Malignant Neoplasm %14 Cerebrovascular Diseases %16 Source Palestinian Ministry Of health annual report(2010)

7 Mortality from CV Disease in West Bank & Gaza Source Palestinian Ministry Of health annual report(2010)

8 Study Introduction > 2 million percutaneous coronary interventions (PCI) are performed annually in the U.S. With coronary stents and adjunctive pharmacotherapy, procedural success has improved to 90% - 95%. The rate of emergency CABG due to procedural complication has decreased to <1%. Several hospitals with cardiac cath labs have developed PCI programs without onsite cardiac surgery and reported satisfactory results in small patient cohorts. In EGH, we adapted this policy on the basis of these facts and due to the prevailing political constrains.. 1. Smith SC, Feldman TE, Hirshfeld JW, et al. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention. J Am Coll Cardiol 2006;47: Anderson HV, Shaw RE, Brindis RG, et al. A contemporary overview of percutaneous coronary interventions. The American College of Cardiology National Cardiovascular Data Registry. J Am Coll Cardiol 2002;39:

9 European Gaza Hospital

10 Total Procedures in EGH 7,000 6,000 5,000 5,982 Total procedure : ,000 3,000 2,000 1, Diagnostic.Cath PCI Peripheral Angioplasty Per. Pacemaker Implantation Arterial Nonsurgical Embolization Septal Reduction ASD Closure Aortic & Pulmonary Valvuloplasty

11 Aim of study To evaluate the safety of PCI without onsite cardiac surgery at the Cardiology Center in European Gaza Hospital

12 METHODS

13 Study Population A total of 814 consecutive patients underwent coronary interventions in our center between November 5 th 2008 and December 31 st All these patients had acute coronary syndrome, angina pectoris or objective evidence of ischemia.

14 Primary End Points In-hospital MACCE throughout the 24hrs period after PCI: Death Stroke MI Emergency CABG Repeated revascularization Vascular complications during cardiac catheterization: Coronary artery thrombus Dissection Perforation

15 Protocol The vast majority of patients underwent elective PCI. All patients received 600 mg loading dose of Clopidogrel(300 mg if the patient was already maintained on), mg aspirin and 100 IU heparin per kg just before the procedure. CK-MB iso-enzymes were drawn 12 hrs after the procedure, and Q 8 hrs if an event of myocardial ischemia was suspected. 12-lead ECG was obtained before and after the procedure (immediately and 12 hrs later) in all patients.

16 Angiographic Analysis Characteristics of lesions Definition Large Diagonal Large diagonal Large OM Normal LAD Narrowing LAD Normal LCX 1 vessel 1 vessel + side branch 1 vessel Large OM Narrowing LCX Any lesion of RCA or PDA Any lesion of any graft 1 vessel + side Branch 1 vessel 1 vessel Any lesion of LM 1 vessel

17 Definition of In-Hospital Clinical Outcomes 1. Angiographic success a. < 20% residual stenosis (stent-treated lesion) or b. < 50% residual stenosis (balloon treated lesion) 2. Procedural success : angiographic success without death, any MI, or emergency CABG 3. Any MI a. Development of new Q waves in >2 contiguous leads or b. CK-MB > 3 ULN If pre-procedure CK-MB is normal c. Increase in CK-MB of at least 50% over previous value If preprocedure CK-MB is > ULN and documentation that CK-MB was decreasing before the suspected recurrent MI.

18 Statistical Analysis We report continuous variables as means ± standard deviation and categorical variables as frequencies and percentages. Patient characteristics were compared between groups using t-tests and chi-square tests, as appropriate. The SPSS for Windows (version 11.5) statistical software package was used for all analysis. A p value < 0.05 was considered statistically significant.

19 RESULTS

20 Total 814 Sex Male 619 (76%) Female 195 (24%) No. of vessels treated at the same setting One Two Three

21 Baseline Characteristics Total Male Female P Value Age ± ± ± No of patients Ns 1 vessels vessels vessels 8 8 History of CABG 87 (10.7%) Ns History of PCI 213 (26.2%) Ns DM 302 (37.1%) Ns

22 Type of PCI %2 %98 Elective & Urgent 798 Primary 16

23 Target Vessel Male Female LAD LCX RCA LM Side branch SVG Total LAD LCX RCA LM Side branch SVG Total Female Male

24 Protected Vs. Unprotected LM procedures Protected vs Unprotected Protected Unprotected

25 Unprotected LM Lesion Localization Ostial +/-Main Shaft Distal+/- Bif 4 2 0

26 Same age and predicted risk One passes the eyeball test one does not

27

28

29

30

31

32 Complications Total Male Female Dissection Perforation Thrombus CVA Death MI Repeat revascularization Urgent CABG 0 0 0

33 RCA perforation

34 LM-LAD DISSECTION

35 Angiographic and procedure success Angiographic success (781 cases): 95. 9% Procedure success (772): 94. 7%

36 Conclusion Our experience in cardiology center at EGH support the safety and efficacy of PCI at hospitals without on-site cardiac surgery including LM & Multi- Vessel interventions.

37 NEVER FORCE TOO MUCH An experienced interventional cardiologist knows how to perform a PCI procedure, a very skillful interventional cardiologist knows how to perform better PCI, The best Interventional Cardiologist knows when not to perform a PCI THANK YOU FOR YOUR ATTENTION hassan.zammar@gmail.com