Presentation is loading. Please wait.

Presentation is loading. Please wait.

How to do primary angioplasty “Conundrums” Dr Adrian Banning John Radcliffe Oxford.

Similar presentations


Presentation on theme: "How to do primary angioplasty “Conundrums” Dr Adrian Banning John Radcliffe Oxford."— Presentation transcript:

1 How to do primary angioplasty “Conundrums” Dr Adrian Banning John Radcliffe Oxford

2 MY CONFLICTS OF INTEREST ARE Advisory Boards- Medtronic, Boston, Cordis Research funding- Boston Oxford Live sponsors- Boston, Elli lilly, Edwards

3 First thought “Conundrums in PPCI”

4 Second thought “Conundrums in PPCI”

5 What is a “condundrum?” A paradoxical, insoluble, or difficult problem;

6 How can we improve PPCI 1)What can we do in the ambulance? 2)What can we do in the lab? 3)What can we do afterwards

7 Improving PPCI in the ambulance Optimal primary and Optimal primary and –secondary prevention Call to Help “CONUNDRUM” Call to Help “CONUNDRUM” –Public education Arrive to depart Arrive to depart –ECG diagnosis –Near patient testing? –Minimise reassurance stops

8 Improving PPCI in the ambulance How do we deal with long transfer times? CONUNDRUM Either a Composite lytic strategy? Enhanced transfer capacity? Per conditioning?

9

10

11

12

13 Has lysis got a role…… Opinion Remember Remember –The falling incidence of AMI –Individual Paramedic experience of lysis –Geographical proximity in most UK So……FORGET LYSIS So……FORGET LYSIS –But if Lytic then direct to HAC

14 Reperfusion is a complex process Reperfusion also causes paradoxical tissue injury – eg myocardial stunning, ‘no reflow’ Reperfusion also causes paradoxical tissue injury – eg myocardial stunning, ‘no reflow’ It is possible that modulating reperfusion injury will improve the outcomes of reperfusion therapies It is possible that modulating reperfusion injury will improve the outcomes of reperfusion therapies

15 Mechanism Circulating mediator – direct effector Circulating mediator – indirect effector Circulating mediator – neural pathway Neural pathway Systemic effects eg. circulating cells Distant tissue effects

16 rIPerC during transfer to primary PCI: Condi trial Ambulance Patient ECG Randomization

17 Inclusion Criteria Symptoms lasting > 30 minutes and < 12 hours ST-segment elevation ≥ 0.1 mV in 2 contiguous leads Age ≥ 18 years Informed consent

18 Primary Endpoint: Myocardial Salvage Index Acute scan: Area-at-risk (AAR) Salvage index = (AAR-FIS)/AAR One month scan: Final infarct size (FIS)

19 Final infarct size at 30 days ST-segment resolution Troponin T release Corrected TIMI Frame Count LV function by echocardiography MACE at 30 days Secondary Endpoints

20 Pre-hospital randomization n=333 Pre-hospital randomization n=333 PCI only (n=167) PCI only (n=167) rIPerC (n=166) rIPerC (n=166) 22 did not meet inclusion criteria PCI only (n=145) PCI only (n=145) rIPerC (n=147) rIPerC (n=147) 19 did not meet inclusion criteria 110 final infarct size 69 with salvage index 110 final infarct size 69 with salvage index 20 previous MI PCI only (n=125) PCI only (n=125) rIPerC (n=126) rIPerC (n=126) 21 previous MI 109 final infarct size 73 with salvage index 109 final infarct size 73 with salvage index 3 dead 11 consent withdrawn 1 CABG 3 dead 11 consent withdrawn 3 CABG

21 p=0.83 Infarct Related Artery PCI only rIPerC RCA LAD CX

22 Primary Endpoint: Myocardial Salvage Index p=0.033 Salvage Index (median [IQR]) PCI onlyrIPerC PCI only rIPerC Bøtker et al. Lancet 2010;373:727-34

23 Area at Risk Final infarct size Salvage p=0.97 p=0.10 Scintigraphic Data % of LV (median [IQR]) PCI only rIPerC p=0.037 Bøtker et al. Lancet 2010;373:727-34

24 Relation Between AAR and FIS Difference in slope: 0.16 (0.05; 0.26), p = Area at risk (% of LV) Final infarct size (% of LV) PCI only rIPerC

25 Improving PPCI in the ambulance How do we deal with long transfer times? CONUNDRUM ? Optimal paramedic antiplatelet treatment Optimal transfer Per-conditioning strategies Optimal performance of HAC

26 How can we improve PPCI 1)What can we do in the ambulance? 2)What can we do in the lab? 3)What can we do afterwards

27 Can we improve PPCI in the lab Optimal pharmacology ic Reopro? Adjunctive devices aspiration alone? Optimal stent choice DES vs BMS Supporting the recovering ventricle

28 Can we improve PPCI in the lab Optimal pharmacology ic Reopro? Cicero trial. Gu et al Outcome Intracoronary abciximab Intravenous abciximab p Complete ST-segment resolution (%) Myocardial blush grade 2/3 (%) Mean enzymatic infarct size (creatine kinase levels in U/L) Major adverse cardiac events (%)

29 Do we need a special stent for AMI? Can we minimise ? Can we minimise ? –Late acquired malaposition –Downstream embolisation M Guard M Guard Stentys Stentys

30 M Guard stent Stent covered with an ultra-thin, micron-level, flexible mesh sleeve fabricated by circular knitting. Stent covered with an ultra-thin, micron-level, flexible mesh sleeve fabricated by circular knitting. During stent deployment, the net stretches and slides over the expanding stent struts, creating custom designed pores parallel to the arterial wall. During stent deployment, the net stretches and slides over the expanding stent struts, creating custom designed pores parallel to the arterial wall. Once in place, MGuard captures embolic debris between the fibre net and the arterial wall and isolates the pro- thrombotic intima components from the bloodstream. Once in place, MGuard captures embolic debris between the fibre net and the arterial wall and isolates the pro- thrombotic intima components from the bloodstream.

31 Current issues in PCI for ACS Undersizing 2 / Underexpansion 3 Early and/or late Malapposition Acute / Sub-Acute Thrombosis Thrombus dissolution 1 Vasodilation 1 Stent recoil 4 ? 1. 1.C. Spaulding, “Clinical Application of a Novel Self-expanding Coronary Stent in AMI” Europ. Cardio 2009;5(2): Van Werkum J.W. “Predictors of Coronary Stent Thrombosis” JACC :16: Stéphane Cook and Stephan Windecker, Circulation 2009;119; Stéphane Cook, Circulation 2007;115; Renu Virmani, MD, of CVPath Institute (Gaithersburg, MD) in a telephone interview with TCTMD 6. 6.Ozaki Y, Okumura M, Ismail TF, et al. The fate of incomplete stent apposition with drug-eluting stents: An optical coherence tomography-based natural history study. Eur Heart J. 2010; (31), Malapposition is a significant risk factor for stent thrombosis 3,5 31 Thrombus occurred more often when there is incomplete stent apposition than in well-apposed stents (20.6% vs. 2.0%; P < ) 6

32 STENTYS ® Technology Nitinol, self-apposing stent (BMS and DES) 6F single-wire, rapid exchange, CE-marking Disconnectable struts over full length * 32 Disconnectable interconnector DisconnectionDisconnectors along the stent * Except the first and last 2mm Product not available for sale in the United States

33 1. Position the STENTYS ® stent over the lesion 2. Retract the outer sheath to deploy the stent from distal to proximal 3. The stent is fully deployed in the vessel of the AMI patient with perfect apposition 4. The STENTYS ® stent expands with the vessel during vasodilation and as thrombus resolves ensuring perfect apposition. Deploying a STENTYS ® Self-Apposing Stent in an AMI patient Product not available for sale in the United States 33

34 Malapposition in a STEMI patient 3 day OCT pictures from the STENTYS ® Apposition II Trial 3 day malapposition of a conventional stentPerfect apposition at 3 days of the STENTYS ® Self-Apposing Stent Conventional stent STENTYS ® Self-Apposing Stent Product not available for sale in the United States 34

35 How can we improve PPCI - the lab We don’t always get perfect coronary flow We don’t always get perfect coronary flow –Late presentation –Large thrombus load “CONUNDRUM” –“no reflow” “CONUNDRUM” pretreatment is the key Hyperbaric oxygen therapy- HOT AMI Hyperbaric oxygen therapy- HOT AMI Systematic cooling during AMI Systematic cooling during AMI

36 Reveal- EPO in AMI EPO or matching saline placebo. EPO or matching saline placebo. 68 patients were treated with units of EPO and compared with 70 patients randomized to placebo. 68 patients were treated with units of EPO and compared with 70 patients randomized to placebo. Compared with placebo, the administration of EPO following successful primary or rescue PCI did not reduce infarct size, as assessed by MRI at two to six days and at 12 weeks. Compared with placebo, the administration of EPO following successful primary or rescue PCI did not reduce infarct size, as assessed by MRI at two to six days and at 12 weeks. No improvement in early or late measurements of left ventricular remodeling. No improvement in early or late measurements of left ventricular remodeling. In fact, investigators observed a trend toward harm among older patients, with a larger infarct size among those >70 years of age treated with EPO. In fact, investigators observed a trend toward harm among older patients, with a larger infarct size among those >70 years of age treated with EPO.

37 How can we improve PPCI 1)What can we do in the ambulance? 2)What can we do in the lab? 3)What can we do afterwards?

38 How can we improve PPCI What can we do afterwards? Risk assesment of those patients with Multi- vessel disease “CONUNDRUM” Severe LV impairment Integrated early rehabilitation Effective smoking cessation Prolonged drug compliance in those at highest risk

39 How can we improve PPCI- the POLITICS

40 Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments – Emergency Response (RACE-ER) Project on behalf of RACE Coordinators, Nurses, Physicians, Paramedics, and Administrators

41 Regional approach to overcoming systematic barriers 1) Increase reperfusion rate 2) Increase speed of reperfusion RACE Pilot RACE 65 hospitals RACE - ER 119 hospitals Objectives

42 Transfer: First Door to Device Times (For hospitals with designated transfer strategy) (85, 127) (93, 155) (91, 153) (93, 155) (94, 145) (89, 134) p= (85, 127) (93, 155) (91, 153) (93, 155) (94, 145) (89, 134)

43 Outcomes, In-hospital PrePost n Death5.8%5.7% Death, no shock # 3.4%2.6% Death, shock # 29.3%34.8% Bleeding6.8%5.1% Shock after admission6.3%5.9% CHF6.5%8.1% Stroke1.7%1.2% Re-infarction0.9%0.9% # shock at presentation

44 Mortality

45 BMJ Feb 2008 …treatment delays can be reduced by prehospital diagnosis and direct transfer to a high volume catheter lab

46 Nearest centre isnt always quickest access Ht attack centre lab

47 Nearest centre isnt always quickest treatment 30 mins 30 mins DTB 30 mins DTB 30 mins Total 60 mins Total 60 mins Ht attack centre lab 10 mins DTB 60 mins Total 70 mins

48 r = % CI of r = to p = Slope = -9.5 secs/n

49 How can we improve PPCI- the politics Hospitals receiving PPCI pts Hospitals receiving PPCI pts –9-5 Mon-Fri –No 24/7 cardiology on-call –Door to balloon 2x HAC time –Centre geographically in one place claims to be somewhere else! CONUNDRUM!!!

50 HAC Door to balloon In 2012 ALL HACs should be aiming for mean/median Door to balloon <45 mins In 2012 ALL HACs should be aiming for mean/median Door to balloon <45 mins Ultimate target for all centers 30 mins Ultimate target for all centers 30 mins

51 Getting the best from PPCI ? - conclusions Define optimal management during transfer Define optimal management during transfer –Network strategy –Drugs in the ambulance –Pre/postconditioning? Define optimal lab management Define optimal lab management –Devices –drugs Devise mechanical support strategies to facilitate recovery Devise mechanical support strategies to facilitate recovery Rationalise the politics to help sustainability. Rationalise the politics to help sustainability.


Download ppt "How to do primary angioplasty “Conundrums” Dr Adrian Banning John Radcliffe Oxford."

Similar presentations


Ads by Google