5/11/14 Revascularisa0e strategie bij acuut myocardinfarct en meertaks coronairlijden Pranobe Oemrawsingh Krishna Khargi Cardioloog Thoraxchirurg MCH Den Haag MUMC+ Maastricht Disclosures • P. Oemrawsingh – Geen • K. Khargi – Consultant Medtronic 1 5/11/14 Introduc0e • 40-‐60 % of ptn met STEMI heeT meertaks coronairlijden (MVD) • Slechtere overleving Soraijja et al ; EHJ 2007 Guidelines • Guidelines ACCF/AHA/SCAI (2011) /ESC (2012) – Culprit lesion only unless: • Cardiogenic shock • Residual ischemia – Argumenta0e: • • • • PCI trombo0sch geac0veerd en inflammatoir milieu Complica0es gerelateerd aan non-‐culprit vessel PCI Overscha_ng van non-‐culprit stenosen CIN • Retrospec0eve en kleine observa0onele studies 2 5/11/14 Dagelijkse prak0jk • Verbetering in PCI – Materialen – Technieken – Farmacotherapie • Procedure / technieken buiten de bestaande richtlijnen » 1-‐stage PCI (Immediate preven0ve PCI) » Gestageerde revascularisa0e Mogelijke risico’s en voordelen MV PCI 3 5/11/14 Conclusion: This meta-‐analysis supports current guidelines discouraging performance of mul0vessel primary PCI for STEMI. When significant nonculprit vessel lesions are suitable for PCI, they should only be treated during staged procedures. JACC 2011 Culprit Vessel Only versus Mul0vessel Percutaneous Coronary Interven0on in Pa0ents Presen0ng with ST-‐ Segment Eleva0on Myocardial Infarc0on and Mul0vessel Disease • 4 randomized and 14 nonrandomized studies involving 39,390 pa0ents were included • MV-‐PCI strategy is associated with – short-‐term mortality (OR: 0.50, 95% CI: 0.32 to 0.77, p = 0.002) – long-‐term mortality (OR: 0.52, 95% CI: 0.36 to 0.74, p<0.001) – Renal dysfunc0on (OR: 0.77, 95% CI: 0.61 to 0.97, p = 0.03) Zhang et al; PloS ONE 2014 4 5/11/14 The REAL Registry: Culprit-‐Only, Immediate, or Staged Mul0vessel PCI Mortality Reinfarc0on TVR MACE Manari et al; Catheteriza0on and Cardiovascular Interven0ons 2014 PRAMI: Randomized Trial of Preven0ve Angioplasty in Myocardial Infarc0on Wald DS et al. N Engl J Med 2013;369:1115-1123 • “preven0ve PCI is a bemer strategy than restric0ng a further interven0on to those pa0ents with refractory angina” • “our findings do not address the ques0on of immediate versus delayed (staged) preven0ve PCI, which would need to be clarified in a separate trial“ NEJM 2013 5 5/11/14 Visie Cardiochirurg Timing Cardiochirurgie “essen0ele” factoren • LV & RV func0e • Bloedingsrisico • Recidief coronairocclusie 6 5/11/14 Bloeding-‐LV/RV-‐recidief Dubbele plaatsjesremmers an0stolling % Bloedingsrisico LV/RV func0e Effect infarct Non-‐infarct segmenten Lokaal Overbelas0ng non-‐infarct segmenten Recidief infarct 0 3 Coronairstenoses non-‐infarct 42 5 Dagen LV func0on –loca0on infarct myocardial infarc0ons of similar size, le, ventricular ejec2on frac2on is lower when apical involvement is extensive and the site of infarc0on is anterior. (related to characteris0cs specific to the apex) American Heart Journal, Volume 140, Issue 2, 2000, 284 - 290 7 5/11/14 LV infarc0on affects RV Prognos2c importance of right ventricular dysfunc2on LV infarc0on LVEDP increase acute inferior myocardial infarc0on Interventricular septum RV aTerload RV impairment recovers m aTer +/-‐10 days (despite persistent impairment of LVEF.) Not reversible Heart 2002;88:323–324 LeT Ventricular Func0on post 1st STEMI with PCI Men Versus Women Female post primary PCI for STEMI: worse systolic and diastolic LV func0on; Median 0me to echocardiography was 1.4 days. (Am J Cardiol 2014 8 5/11/14 Stunning Stunning: 7-‐14 Days to recover Bloeding CABG (n=1899) Preopera0ef stop Ticagrelor 1-‐3 dg; Clopidogrel 5 dg Less CV Less infec0ons % Total death % Cardiovascular death No excess risk of CABG-‐related bleeding (J Am Coll Cardiol 2011;57:672–84) © 2011 by the American College of Cardiology FoundaGon 9 5/11/14 Cardiochirurg: Volgorde denken Frailty ( “breekbaarheid”) Euroscore Individuele levensverwach0ng DM Verminderde LV Syntax score >33 Hoofdstamstenose 3VD Complete arterial CABG: survival en LV func0e 10 5/11/14 Survival Sima vs Bita Survival -‐LV 11 5/11/14 STEMI Herstel myocardiale perfusie Op0maliseren long-‐term outcome Infarct zone Non-‐infarct zone Normalisa0e van flow Local result Impact van rest afwijkingen? Risico van extra interven0e STEMI en MVD M 67 jr Blanco VG 3 uur POB L 185 cm RF: N+ G 95 kg RR 100/60 mm Hg 12 5/11/14 Beslissingen 0jdens primaire PCI • Revascularisa0e methode – PCI – CABG • Timing – Direct – In zelfde opname – Later • Ischemie / Viability? – FFR – Angina – MPS/MRI/Stress TTE • Op0mal Medica0on 13 5/11/14 Complexe beslissingen 0jdens pPCI Pa0ent preference MVD LM / LAD Cogni0ve func0on Syntax score BMI /Frailty FFR Rx MV PCI CABG Bleeding Risk DM Euroscore CIN Comorbidty Age Gender Conclusie • Nog onvoldoende bewijs voor een op0male revascularisa0e strategie bij acuut myocardinfarct en meertaks coronairlijden • Complete revascularisa0e is beter • Gestageerde revascularisa0e lijkt de beste op0e – Methode – Timing • Vele factoren mogelijk van invloed op lange termijn klinisch resultaat • Beslissingen in de acute fase 0jdens pPCI kunnen bepalend zijn voor rich0ng verdere beleid 14
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