ΑΝΤΙΓΝΩΜΙΕΣ ΣΤΗΝ ΕΠΕΜΒΑΤΙΚΗ ΚΑΡΔΙΟΛΟΓΙΑ:Νόσος στελέχους Αγγειοπλαστική

Transcription

1 ΑΝΤΙΓΝΩΜΙΕΣ ΣΤΗΝ ΕΠΕΜΒΑΤΙΚΗ ΚΑΡΔΙΟΛΟΓΙΑ:Νόσος στελέχους Αγγειοπλαστική X. ΓΡΑΪΔΗΣ Επεμβατικός καρδιολόγος, FSCAI Kλινική Euromedica-Κυανούς Σταυρός, Θεσσαλονίκη

2 The Fear factor The two words LEFT MAIN are enough to strike fear into the hearts of most physicians

3 Why do we fear LM disease? High mortality with medical treatment High mortality after surgical treatment High mortality with acute MI and cardiogenic shock associated with LMCAD High mortality with PCI

4 Some facts about Left Main Disease Anatomy 4-6% of patients undergoing coronary angiography. Isolated LMCA stenosis in 5% (more frequent in women) Left main complexities

5 Left Main Disease comes in many sizes and shapes

6 Left Main Disease: Anatomy

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8 2014 ESC/EACTS Guidelines on Myocardial Revascularization LMCA disease is the only lesion subset for which revascularization is unequivocally accepted as improving survival over medical therapy

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10 CABG vs Medical Therapy

11 We have not been too successful in dilating left main stems although the procedure is relatively simple, the potential complications are both serious and sudden A. Gruentzig NEJM1979 PCI for Left Main Disease: Balloon Angioplasty Gruentzig first attempted (unsuccessfully) in 1978 (Lancet 1978;311:263)

12 33 elective, unprotected left main POBA 9.1% procedural mortality 36% 3 year survival Thus, although elective angioplasty of an unprotected LM coronary artery is technically feasible, the long-term prognosis of such patients is very poor. LM angioplasty in this subgroup should be reserved for patients in whom surgical revascularization is not an option.

13 Two Very Different Procedures PCI CABG vs

14 Do all patients with Left Main disease need CABG?

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16 2010

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20 Capodanno D et al. JACC 2011;58:

21 Capodanno D et al. JACC 2011;58:

22 Meta-analysis of 3 RCT and 21 registries , n= 14,203 pts. with ulmca disease, 5 years FU (J Am Coll Cardiol Intv 2013;6: )

23 Meta-analysis of 3 RCT and 21 registries , n= 14,203 pts. with ulmca disease, 5 years FU (J Am Coll Cardiol Intv 2013;6: )

24 New Data from ASAN MAIN registry, 2014

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26 2014 ACC/AHA SIHD Guidelines:UPLM Revascularization for Survival

27 Decision Making Process for Revascularization of Unprotected LMCA lesions In daily routine the selection of the appropriate revascularization strategy for distal ulmca lesions depends on

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29 Studies not designed or powered to definitely answer this question

30 EXCEL trial powered to determine optimal revascularization strategy for SYNTAX score <33.

31 My current decision-making process SYNTAX score > 33: CABG if no contraindication to surgery or if predicted risk of operative mortality < 10%. SYNTAX score < 33: PCI, except in technically complex disease, in patients with diabetes and CRF or in those with severe CRF (if no high predicted surgical risk).

32 When it comes to Left Main PCI

33 Appropriate tools should reach appropriate hands

34 The operator s variable One-year MACCE Rates per site

35 When it comes to Left Main it is crucial to follow the basics rules of PCI Simple Action plan Fast Experience

36 3 major steps Indication of PCI Strategy of PCI Assessment of the final immediate result Strategy of Left Main PCI Left Main PCI 3 major needs High quality angiography imaging equipment High quality of medical & nurse/technician environment Highly experienced operator 3 major objectives Procedure safety: no complications Procedure efficacy: the best angiographic result Long-term clinical efficacy

37 Ostial/Shaft LM Disease

38 Ostial/Shaft LM Disease Chieffo A, Kim YH, Park SJ et al. Circulation 2007;116:158

39 Ostial/Shaft LM Disease

40 Ostial/Shaft LM PCI : DES vs. CABG

41 Ostial/Shaft LM Disease is Not Surgical Disease Anymore in Real Practice Technically Easy and Safe to Perform. Clinical Outcomes of PCI is Comparable to Surgery, Even Better!

42 LM PCI Bifurcation Strategies The bifurcation is involved in over 70% of LM cases Bifurcations are not alike and may differ with regards to: angle, burden of atherosclerotic lesion, relative involvement of LAD/LCX ostia, mismatch of LM and stemming arteries diameters. Simple variables carry a prognostic value and may be useful to drive decisions in distal LM disease, discriminating the bad from good bifurcations.

43 An algorithm to choose between 1 vs 2 stents in the Left Main (and which 2-stent technique) The LCX is one of the key elements for indication of Left Main PCI Size Area of jeopardized myocardium Ostial location of atheroma plaque Diffusion of atheroma Bifurcation angle

44 An algorithm to choose between 1 vs 2 stents in the Left Main (and which 2-stent technique)

45 Naganuma T, JACC Cardiovasc Interv.Dec;6(12):

46 Kang et al. Circ Cardiovasc Interv 2011;4:

47 Ostium/Shaft vs Bifurcation LM PCI GISE/SICI Registry (n = 1,111) PCI with DES has excellent outcomes for ostial or mid-shaft LM lesions, but has a higher incidence of TLR for distal LM bifurcation lesions LM Bifurcations treated with 2 stents have worse outcomes than LM bifurcations treated with 1 stent Palmerini et al. Eur Heart J 2010;30:

48 LM PCI Bifurcation Strategies 1-stent vs 2-stent COBIS (Coronary Bifurcation Stenting) Registry II N= 853 pts. with LM bifurcation lesions, 18 Korean centers, 01/ /2009 Song et al., J Am Coll Cardiol Intv 2014

49 An algorithm to choose between 1 vs 2 stents in the Left Main (and which 2-stent technique)

50 TVR-Free Survival Rate at 12 Months TLR-Free Survival Rate at 12 Months

51 ULMCA Bifurcation Lesions: MACE at 5 yrs: DKC vs Others Zhang YJ, Chen SL; TCT 2013

52 LM PCI Bifurcation Strategies Technique resembles non-left main bifurcations but requires more attention to details PCI of bifurcation associated with high risk of MACE as compared to ostial/mid shaft lesions Optimal strategy is not yet known. Most favor a provisional stent strategy

53 LM PCI optimization To ensure an optimal final result the correct performance of the technique is more important than the choice of the technique itself, and this is what will determine the patient clinical outcome

54 Bifurcation LM PCI : Provisional stenting >80% of LMS bifurcation lesions can be treated with a single stent

55 De la Torre Hernandez et al. JACC Intv 2014;7:

56 De la Torre Hernandez et al. JACC Intv 2014;7:

57 Impact of IVUS guidance Criteria for stent underexpansion at the distal LM bifurcation Smaller MLA predicts restenosis Kang et al. Circ Cardiovasc Interv ;4:

58 The meaning of HEART TEAM

59 It is practical as the Heart Team Advantages reported in the literature improves (consistent) decision (making more accurate according to guidelines) Team has more knowledge than an individual Increases physician and patient wellbeing Higher ratings of patients experience of care Physicians share the burden Improves outcomes Liability But remember Medicine is not a democracy

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62 Treatment decisions should not be based solely on research results and the physician s appraisal of the patient s circumstances, since active patient participation in the decision-making process may yield better outcomes Patient information needs to be unbiased, evidence-based, up-to-date, reliable, accessible, relevant, and consistent with legal requirements. Short-term procedure-related and long-term risks and benefits such as survival, relief of angina, quality of life, potential need for late reintervention, and uncertainties associated with different treatment strategies should be thoroughly discussed. Patients can only weigh this information in the light of their personal values and cultural background and must therefore have the time to reflect on the trade-offs imposed by the outcome estimates

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64 How do we consent suitable patients? While the guidelines do not give left main stenting the highest recommendation and while most doctors are traditionally inclined to send patients such as yourself for bypass surgery, published evidence suggests similar survival rates with bypass and stent procedures..your risk of stroke is definitely 4-5 fold lower with stent procedure, but you do have a higher risk of a repeat procedure due to stent renarrowing. In my opinion a very reasonable option for you is

65 CASE 1 Choice of the HEART TEAM

66 CASE 1-48 y.o. male. - Risk factors for IHD: Hypertension Dyslipidaemia Smoker. - Recent hospitalization for unstable angina

67 Critical stenosis at the ostium of left main

68 Pre PCI The patient remains asymptomatic after 3 years Post PCI FU 6 months

69 CASE 2 Patient s willingness

70 CASE 2-60 y.o. male. - Risk factors for IHD: Hypertension Dyslipidaemia ex-smoker - In June 2006, underwent coronary artery bypass grafting for left main and three vessel disease. LIMA LAD RIMA Ramus intermediate SVG RCA

71 14 months later, presented with unstable angina LMS: severe stenosis LAD: chronic total occlusion RI: severe mid-vessel disease LIMA: occluded SVG RCA: patent RIMA: subtotal occlussion

72 -re- do CABG? -Logistic EUROSCORE: Patient unwilling to undergo surgery for a second time. - PCI? -SYNTAX score: Informed consent.

73 The patient remains asymptomatic 48 months after the 2 nd PCI. Final result IVUS post PCI LM RI LAD

74 CASE 3 The inoperable patient

75 CASE 3-87 y.o. male with unstable angina (repeated hospitalizations) - Risk factors for IHD: Hypertension Dyslipidaemia ex-smoker. - In the last year 2 PCIs in LAD, Cx and OM1 in another hospital

76 LAD: Critical lesion at the ostium (severe calcification) Cx : Severe lesion at the ostium (restenosis,severe calcification) OM1 : Total occlusion (restenosis) RCA: Total occlusion EF 25-30%. Logistic Euroscore SYNTAX score: 38. Informed consent.

77 Pre PCI The patient is free of MACE after 3 years Final result FU 6 months

78 CASE 4 Fighting with a catastrophe. The only option?

79 CASE 4 A 42 years old caucasian woman No any previous medical history or any risk factors for coronary artery disease. Presented to a district general hospital, with no cardiac catheter laboratory facilities, with acute anterior MI, complaining about a sudden-onset substernal chest pain lasting for the past 2h. Thrombolytic treatment was started immediately, with regression of the angina and almost normalization of the ECG changes.

80 On the eighth in hospital day, the patient suffered another episode of substernal chest pain, with hypotension and signs of left ventricular heart failure.

81 Spontaneous Left Main dissection

82 FINAL RESULT Hospital discharge on day 8. Echocardiography at 1 month: ejection fraction was 35% with a moderate mitral regurgitation.

83 A MSCT coronary angiography at 6 months showed the absence of re-stenosis The patient remained asymptomatic at 3 years follow up

84 Long-term outcomes of percutaneous coronary intervention for unprotected left main coronary artery disease: Initial clinical experience. C.GRAIDIS, D.DIMITRIADIS, V.PSIFOS, V.KARASAVVIDIS, G.TSONIS, O.HALVATZOULIS EUROMEDICA KYANOUS STAVROS HOSPITAL THESSALONIKI, GREECE 9o PANHELLENIC CONGRESS Of Hellenic Society of Thoracic and Cardiovascular Surgeons Thessaloniki November 2012

85 METHODS Of 1,376 PCI procedures performed in our institution from January 2007 to February 2011, 52(2.9%) consecutive patients receiving unprotected LMCA intervention were identified using a prospective database. Unprotected LMCA stenosis was defined as >50% diameter stenosis without patent graft to left anterior descending artery (LAD) or left circumflex artery (LCX), nor established collaterals from right coronary artery (RCA). The decision for PCI over other modalities is based on surgical risk, and/or patient/physician preference.

86 Demographic and Clinical data (n=52) Age (yrs) 64,4 1 ± 3,5 Male 42 (80.7%) DM 10 (19.2%) Arterial hypertension 22 (53.8%) Hypercholesterolemia 23 (44.2%) Smoking 28 (53.8%) COPD 4 (7.7%) Peripheral artery disease 3 (5.7%) Previous MI 8 (15.3%) Previous PCI 12 (23.1%) Previous CABG 4 (7.7%) History of stroke 2 (3.8%) Left ventricular ejection fraction <40% 12 (23.1%) NSTE-ACS 27 (51.9%) STEMI 3 (5.8%)

87 Angiographic data (n=52) Isolated LM 16 (30.8%) LM with 1-vessel disease 29 (55.8%) LM with 2-vessel disease 6 (11.5%) LM with 3-vessel disease 1 (1.9%) Ostium involvement 14 (26.9%) Shaft involvement 2 (3.9%) Distal LM involvement 36 (69.2%) Right coronary artery involvement 16 (30.7%) No. of diseased vessels treated per patient Mean Syntax Score 21,49+10,47 SS<22 37 (71.1%) SS >22 and <33 8 (15.4%) SS >33 7 (13.5%)

88 Procedural data (n=52) Mean number of vessels treated per patient (range) Mean number of lesion treated per patient (range) Mean number of stents per patient Mean stent length per patient (mm) Post-Dilatation (%) 100% Single stent in distal LM 30 (83.4%) Kissing post-dilation of distal LM) 21 (58.3%) IABP support 10 (19.2%) IVUS guidance 16 (30.7%) Complete revascularization 41 (78.8%) Procedural success 52 (100%)

89 Clinical outcome (n=52) Follow-up period (months) Death 0 (0%) Myocardial infarction 0 (0%) Stroke 0 (0%) Repeat revascularization 5 (9.61%) PCI 5 (9.61%) CABG 0 (0%) Stent Thrombosis 0 (0%) MACE 5 (9.61%)

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