Revascularization : A Forgotten Art Ja James es He Hermil ille - - PowerPoint PPT Presentation

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Revascularization : A Forgotten Art Ja James es He Hermil ille - - PowerPoint PPT Presentation

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Optimizing Percutaneous Coronary Interventions Spo Sponsored by y th the Car Cardiovascula lar Res esearch Foundatio ion 21 st st , 2019 Tuesday, May 21 2019 Complete Coronary Revascularization : A Forgotten Art Ja James es He Hermil

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Complete Coronary Revascularization: A Forgotten Art

Optimizing Percutaneous Coronary Interventions

Spo Sponsored by y th the Car Cardiovascula lar Res esearch Foundatio ion Tuesday, May 21 21st

st, 2019

2019

Ja James es He Hermil ille ler, MD, MSCAI, FACC St t Vin incent Med edical Group, St t Vin incent He Heart Ce Center of

  • f In

India iana In India ianapoli lis, IN IN

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Disclosure Statement of Financial Interest

  • Grant/Research Support
  • Consulting Fees/Honoraria
  • Edwards, Medtronic, Abbott, St

Jude, BSC, BIOTRONIK

  • Edwards, Medtronic, Abbott, St

Jude, BSC,BIOTRONIK

Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below.

Affiliation/Financial Relationship Company

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Outline

  • Introduction
  • Impact of Ischemia on Outcome
  • Complete Revascularization
  • Anatomic Complete Revascularization
  • Physiologic Complete Revascularization
  • Case Reviews
  • Summary and Conclusions
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Why Incomplete Revascularization?

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PET Ischemia and Cardiac Death

Dorbala S et al. JACC 2013;61:176–84

Rest/stress rubidium-82 PET MPI performed in 7,061 pts at 4 centers; Median FU 2.2 years

MVA: HR↑ by 34% and 57% for each 10% increase in %myo ischemic and scarred, respectively (each P<0.001).

Adj HR [95%CI] 4.9 [2.5, 9.6], P<0.0001] 4.2 [2.3, 7.5] P<0.001] 2.3 [1.4, 3.8], P=0.001 Cardiac Death Follow-up (years) ≥20%

Reference

10-19.9% 0.1-9.9% 0%

1.00 2.00 3.00 4.00 5.00 0.00 0.05 0.10 0.15 0.20 HR 12.9 (95% CI 7.8-21.4), P<0.0001 HR 8.1 (95% CI 4.7-14.0), P<0.0001 HR 2.8 (95% CI 1.7-4.7), P<0.0001

% abnormal myocardium

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0.0% 15.6% 22.3% 39.3%

0% 10% 20% 30% 40%

Death or MI Rate (%)

Rates of Death or MI by Residual Ischemia on 6-18m MPS

p=0.002 0% (n=23) p=0.023 p=0.063 1%-4.9% (n=141) 5%-9.9% (n=88) >10% (n=62)

Shaw, et al, AHA 2007 and Circulation 2008

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Meta-analysis: All-Cause Mortality

PCI Better Study

1

Hazard Ratio (95% CI) % Weight (I-V)

.1 10

MT Better COURAGE AHJ 0.62 (0.30, 1.28) 60.3 FAME-2 0.33 (0.03, 3.17) 33.8 SWISSI-II 0.42 (0.16, 1.11) 5.9 Fixed Effects (I2=0.0%, p=0.84) 0.52 (0.30, 0.92) p=0.02 Random Effects 0.52 (0.30, 0.92) p=0.02

  • Pts with ischemia by noninvasive imaging or FFR -

n=1,557 randomized

Gada H et al. Am J Cardiol 2015;115:1194-9

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Outline

  • Introduction
  • Impact of Ischemia on Outcome
  • Complete Revascularization
  • Anatomic Complete Revascularization
  • Physiologic Complete Revascularization
  • Case Reviews
  • Summary and Conclusions
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Does Complete Revascularization Matter?

SCAAR Registry of 23,342 patients undergoing PCI for MVD and comparing anatomic complete vs. incomplete revascularization

Hambraeus K, et al J Am Coll Cardiol Intv 2016;9:207-215.

Death, MI, Revasc P<0.0001

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Does Complete Revascularization Matter?

Meta-analysis of 63,945 patients with MVD undergoing PCI

Garcia S, et al J Am Coll Cardiol 2013;62:1421-31.

Mortality Favors Complete Revascularization Favors Incomplete Revascularization

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Does Complete Revascularization Matter?

Pooled analysis of 3 randomized trials (3,280 patients) comparing anatomic complete

  • vs. incomplete revascularization with PCI and CABG and 5 year outcomes

Ahn, et al. J Am Coll Cardiol Intv 2017;10:1415-24.

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Definitions of Complete Revascularization

  • Numerical:

 Number of distal anastomosis ≥ number of diseased

coronary segments

  • Score-based:

 Different weight given to different vessels according to

number of myocardial segments supplied. A residual score of 0 = complete revasc

  • Physiology-based (Functionally Complete)

 All lesions with low FFR/iFR receive a graft/stent

Sandoval Y, et al. J Thorac Dis 2016;8:E1493

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FAME 2: Five Year Follow-Up

5 year rate of death, MI or urgent revascularization in 881 patients with ischemic FFR values randomized to PCI or medical therapy

Xaplanteris, et al. New Engl J Med 2018.

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FAME 2: Five Year Follow-Up

Xaplanteris, et al. New Engl J Med 2018 P=0.04

5 year rate of spontaneous MI in 881 patients with ischemic FFR values randomized to PCI or medical therapy The more severe the FFR, the higher the event rate.

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RSS after Angio-guided PCI

Farooq, V et al. Circulation 2013;128(2):141-51

RSS was strongly correlated with outcome in the SYNTAX trial after angiography-guided PCI.

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Residual SYNTAX Score

Residual SYNTAX Score calculated in FFR-guided patients from FAME

Kobayashi, et al. JACC 2016;67:1701-11.

After functionally complete revascularization with FFR guidance, the residual coronary disease does not predict outcomes.

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Residual Functional SYNTAX Score

385 patients underwent 3 vessel FFR and PCI. Functionally complete revascularization (residual functional SYNTAX score<1) was compared with functionally incomplete revascularization (rFSS≥1)

Choi, et al. J Am Coll Cardiol Intv 2018;11:237-45.

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Outline

  • Introduction
  • Impact of Ischemia on Outcome
  • Complete Revascularization vs Medical

Therapy vs CABG

  • Anatomic Complete Revascularization
  • Physiologic Complete Revascularization
  • Case Reviews
  • Summary and conclusions
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Challenging PCI: Pull Out Your Hair Tough

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Chronically

Reasons for ICR after PCI: CTO

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Reasons for ICR after PCI: Calcium

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Reasons for ICR after PCI: Bifurcations

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Reasons for ICR after PCI: Hemodynamics

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STS score SYNTAX score

Anatomy vs. Morbidity Complex Patients

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You Need a Full Tool Belt

Micro-Catheter

Wires Wiggle Wire Guide-Extender

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  • 85 year old with AS and

unstable angina

  • PVD, CR 1.6 mg/dl
  • Mild COPD
  • CHF and syncope
  • EF 40% and moderate MR

History

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Case Example

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Case Example

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Case Example

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Case Example

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Case Example

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Case Example

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F/U Discharge TAVR in Two Weeks

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  • 77 year old man presented with unstable

angina

  • He had a history of prior inferior MI and

multiple prior PCIs with chronic total

  • cclusion of the LAD at a prior proximal

stent site

  • He had multiple co-morbidities including

prior mantle radiation, myasthenia gravis, COPD, and PAF.

History

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  • His ejection fraction was 30% with global

hypokinesis (S/P BIV ICD)

  • He had been turned down for CABG by

several programs

  • Large area of anterior/septal/apical an apical

inferior ischemia

  • He underwent catheterization at the

referring institution 2 months prior to his presentation at St Vincent hospital

History

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SHY

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Looks Like Something to Dilate

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  • Continued to have unrelenting

angina

  • Referred for 5th opinion

History

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Balloon Dilatation

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3.5 x 8 mm length NC – 15, 19, 25 ATM Manish ATM

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LASER Drill Cutting Balloon Higher Pressure

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Laser Bomb Failed 2 mm Burr Long Runs

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3.5 NC 10 ATM

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Post Dilatation

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Follow Up

  • Angina free
  • Back to Work
  • EF 45%
  • Golfing
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Outline

  • Introduction
  • Impact of Ischemia on Outcome
  • Complete Revascularization vs Medical

Therapy vs CABG

  • Anatomic Complete Revascularization
  • Physiologic Complete Revascularization
  • Case Reviews
  • Summary and conclusions
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Summary and Conclusions

  • Compelling correlation between residual

ischemia and survival/MACE.

  • Anatomic complete revascularization with PCI

compares favorably with CABG.

  • Functionally complete revascularization guided

by FFR/iFR may result in even better outcomes with PCI.

  • Incomplete revascularization is most often a

consequence of untreated complex disease.

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How to Prevent Incomplete Revascularization?

Do Both!

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Thanks for your attention!