DECLARATION OF CONFLICT OF INTEREST
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1 DECLARATION OF CONFLICT OF INTEREST
2 Multivessel disease and cardiogenic shock: CABG is the optimal revascularization therapy. Contra Prof. Christian JM Vrints
3 Cardiogenic Shock Spiral Acute Myocardial Infarction LV-Dysfunction systolic diastolic Inotropes/ Vasopressors Cardiac Output Stroke volume LVEDP Lung edema Mechanical Support: IABP/LVAD Reperfusion: PCI/CABG Peripheral Perfusion Vasoconstriction Fluid retention Hypotension Coronaryperfusion Ischemia Hypoxia Progressive LV-Dysfunction Death Thiele et al. Eur Heart J 2010;31:
4 Cardiogenic Shock Spiral Acute Myocardial Infarction LV-Dysfunction systolic diastolic Inotropes/ Vasopressors + + SIRS Cardiac Output Stroke volume LVEDP Lung edema Mechanical Support: IABP/LVAD Reperfusion: PCI/CABG + Bleeding/ Transfusion + enos inos NO Peroxynitrite IL-6 TNF-α Peripheral Perfusion Vasoconstriction Fluid retention Hypotension Coronaryperfusion Ischemia Hypoxia Progressive LV-Dysfunction SVR Pro-Inflammation Catecholamine sensitivity Contractility Death SIRS: Systemic Inflammatory Response Syndrome Thiele et al. Eur Heart J 2010;31:
5 Many good reasons not to perform urgent CABG in cardiogenic shock STEMI = a clinical storm worst setting for performing a CABG Increased risks for complications ~prothrombotic and inflammatory milieu in the early phase of acute MI: aggravation of SIRS lesion severity in nonculprit vessels is frequently overestimated ~diffuse coronary vasoconstriction
6 What do the guidelines recommend? ESC STEMI Guidelines 2008 Primary PCI Class level Preferred treatment if performed by an experienced team as soon as possible after FMC I A Time from FMC to balloon inflation should be <2 h in any case and <90 min in patients presenting early (e.g.,2 h) with large infarct and low bleeding risk Indicated for patients in shock and those with contraindications to fibrinolytic therapy irrespective of time delay I B I B F Van de Werf et al. Eur Heart J 2008; 29,
7 What do the guidelines recommend? ESC - myocardial revascularization 2010 Emergency angiography and revascularization of all critically narrowed arteries by PCI/CABG as appropriate is indicated in patients in cardiogenic shock. Class of recommendation : Level of evidence: Evidence : SHOCK trial I B W Wijns et al. 2010
8 The SHOCK Trial has been the most important study for management guidelines in patients with cardiogenic shock JS Hochman et al. N Engl J Med 1999;341:625-34
9 Survival % Early Revascularization and 1 Year Survival-SHOCK trial Medical therapy Revascularization p=0.11 p=0.03 p= % absolute increase in 1 year survival in patients assigned to early revascularization number needed to treat of <8 patients to save 1 life days 6 months 1 year JS Hochman et al. JAMA. 2001;285:
10 SHOCK trial: CABG vs. PCI PCI (%) CABG (%) p-value Diabetes LMCA vessel disease coronary jeopardy score 7.1± ± HD White et al. Circulation. 2005;112:
11 SHOCK trial : important limitations! No randomization between PCI or CABG: selection bias undoubtedly influenced results Old fashioned PCI methods: Low use of coronary stents SHOCK: 37% SHOCK registry: 24% Low use of IIb IIIa antagonists: SHOCK: 69% SHOCK registry: 7% No use of bivalirudin or DES No thrombus aspiration
12 Influence of Stenting and IIb/IIIa Inhibition (ACC-NCDR) LW Klein et al. Am J Cardiol 2005;96:35 41
13 Decreasing in-hospital mortality with increasing rates of early PCI in patients with cardiogenic shock STEMI registry Germany % ,2 early PCI 67,7 mortality 56,1 46, ,1 U Zeymer et al. ESC Congress Barcelona 2009
14 Eur Heart Journal ,
15 Multivessel PCI during STEMI is associated with higher short- and long-term mortality HORIZONS-AMI 1 Meta-Analysis 2 1-time multivessel PCI Staged multivessel PCI Multivessel vs. Staged PCI Culprit vs. Staged PCI Culprit vs. Multivessel PCI 30 day mortality Odds Ratio 1. R Kornowski et al. JACC 2011;58: PJ Vlaar et al. JACC 2011;58:
16 SHOCK trial: angiographic & PCI findings Multivessel disease 81% PCI of infarct related artery only 87% Complete revascularization 23% HD White et al. Circulation. 2005;112:
17 SHOCK trial: CABG vs. PCI 1 year survival PCI CABG In selected patients with cardiogenic shock & % P=0.69 P=1.00 P=0.45 multivessel disease early PCI of the culprit lesion only seems a valuable 0 1VD or 2VD 3VD LMCA alternative for emergency CABG.
18 STEMI with cardiogenic shock: single or. multivessel PCI? In hospital outcomes shock pts. National Cardiovascular Data Registry Odds ratios mortality 1 vessel PCI Multivessel PCI Patients p value Death 27.8% 36.5% <0.01 Death in lab 2.7% 5.8% 0.25 Stroke 1.5% 2.6% 0.18 Bleeding 12.5% 13.8% 0.44 Renal failure 7.1% 9.7% 0.03 Multi- vs. 1-vessel PCI MA Cavender et al. Am J Cardiol 2009;104:
19 Cardiogenic Shock: CABG or PCI for Left Main Disease? SHOCK trial & registry PCI procedural details Multivessel PCI 11.1% Stenting 28.4% IIB-IIIA used 6.6% Patients turned down by the surgeons? MS Lee et al. Ann Thorac Surg 2008;86:29-34
20 GRACE registry: unprotected left main revascularization in ACS Cumulative mortality In-hospital death PCI CABG PCI conservative CABG % P= ,4 40 P= P= Days since admission 0 all pts. n=1797 SCD or Shock n=59 STEMI or LBBB n=627 G Montalescot et al. Eur Heart J 2009; 30;
21 GRACE registry: unprotected left main revascularization in ACS Temporal trends in GRACE score severity (A) and type of revascularization (B) Timing of revascularization G Montalescot et al. Eur Heart J 2009; 30;
22 PCI for Left Main Disease in Acute MI Period Patients n Cardiogenic shock (%) Stents used (%) IIb-IIIa Used (%) Early Mortality (%) SHOCK Late Mortality (%) (follow up) G De Luca et al (37±23 months) SW Lee et al (39±22 months) MS Lee et al (586±431 days) CH Tan et al (420 days) SB Prasad et al (26±12 months) Pappalardo A et al (61% DES) GB Pedrazzini et al (78% DES) (CS) 10.5 (1 year) NA G De Luca et al. Am J Cardiol 2003;91: SW Lee et al. Int J Cardiol 2004;97:73-76 MS Lee et al. Ann Thorac Surg 2008;86:29-34 CH Tan et al. Int J Cardiol 2008;126: SB Prassad et al. Catheter Cardiovasc Interv 2009;73: A Pappalardo et al. JACC Intv. 2011;4; GB Pedrazzini et al. JACC Intv 2011;4;
23 Conclusion Patients with cardiogenic shock with multivessel and/or unprotected left main coronary artery disease are a high-risk group In these patients, PCI of the culprit lesion followed by elective PCI of the non culprit lesions is a feasible treatment option associated with reasonably good outcomes
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