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

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 ille ler, MD, MSCAI, FACC St t Vin incent Med edical Group, St t Vin incent He Heart Ce Center of of In India iana In India ianapoli lis, IN IN

Disclosure Statement of Financial Interest 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 • • Grant/Research Support Edwards, Medtronic, Abbott, St Jude, BSC, BIOTRONIK • Edwards, Medtronic, Abbott, St • Consulting Fees/Honoraria Jude, BSC,BIOTRONIK

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

Why Incomplete Revascularization?

PET Ischemia and Cardiac Death Rest/stress rubidium-82 PET MPI performed in 7,061 pts at 4 centers; Median FU 2.2 years HR 12.9 (95% CI 7.8-21.4), P<0.0001 Adj HR [95%CI] HR 8.1 (95% CI 4.7-14.0), P<0.0001 % abnormal myocardium 0.20 HR 2.8 (95% CI 1.7-4.7), P<0.0001 ≥20% 4.9 [2.5, 9.6], Reference P<0.0001] Cardiac Death 0.15 10-19.9% 4.2 [2.3, 7.5] 0.10 P<0.001] 0.05 0.1-9.9% 2.3 [1.4, 3.8], 0% P=0.001 0.00 1.00 2.00 3.00 4.00 5.00 0 Follow-up (years) MVA: HR↑ by 34% and 57% for each 10% increase in %myo ischemic and scarred, respectively (each P<0.001). Dorbala S et al. JACC 2013;61:176 – 84

Rates of Death or MI by Residual Ischemia on 6-18m MPS p=0.002 39.3% 40% Death or MI Rate (%) p=0.023 30% p=0.063 22.3% 20% 15.6% 10% 0.0% 0% 0% 1%-4.9% 5%-9.9% >10% (n=23) (n=141) (n=88) (n=62) Shaw, et al, AHA 2007 and Circulation 2008

Meta-analysis: All-Cause Mortality - Pts with ischemia by noninvasive imaging or FFR - n=1,557 randomized Hazard Ratio % Weight Study (95% CI) (I-V) 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 (I 2 =0.0%, p=0.84) p=0.02 0.52 (0.30, 0.92) Random Effects p=0.02 0.52 (0.30, 0.92) .1 1 10 PCI Better MT Better Gada H et al. Am J Cardiol 2015;115:1194-9

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

Does Complete Revascularization Matter? SCAAR Registry of 23,342 patients undergoing PCI for MVD and comparing anatomic complete vs. incomplete revascularization Death, MI, Revasc P<0.0001 Hambraeus K, et al J Am Coll Cardiol Intv 2016;9:207-215.

Does Complete Revascularization Matter? Meta-analysis of 63,945 patients with MVD undergoing PCI Mortality Favors Incomplete Favors Complete Revascularization Revascularization Garcia S, et al J Am Coll Cardiol 2013;62:1421-31.

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.

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

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.

FAME 2: Five Year Follow-Up 5 year rate of spontaneous MI in 881 patients with ischemic FFR values randomized to PCI or medical therapy P=0.04 The more severe the FFR, the higher the event rate. Xaplanteris, et al. New Engl J Med 2018

RSS after Angio-guided PCI RSS was strongly correlated with outcome in the SYNTAX trial after angiography-guided PCI. Farooq, V et al. Circulation 2013;128(2):141-51

Residual SYNTAX Score Residual SYNTAX Score calculated in FFR-guided patients from FAME After functionally complete revascularization with FFR guidance, the residual coronary disease does not predict outcomes. Kobayashi, et al. JACC 2016;67:1701-11.

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.

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

Challenging PCI: Pull Out Your Hair Tough

Reasons for ICR after PCI: CTO Chronically

Reasons for ICR after PCI: Calcium

Reasons for ICR after PCI: Bifurcations

Reasons for ICR after PCI: Hemodynamics

Anatomy vs. Morbidity Complex Patients STS score SYNTAX score

You Need a Full Tool Belt Micro-Cathete r Wires Wiggle Wire Guide-Extender

History • 85 year old with AS and unstable angina • PVD, CR 1.6 mg/dl • Mild COPD • CHF and syncope • EF 40% and moderate MR

Case Example

Case Example

Case Example

Case Example

Case Example

Case Example

F/U Discharge TAVR in Two Weeks

History • 77 year old man presented with unstable angina • He had a history of prior inferior MI and multiple prior PCIs with chronic total occlusion of the LAD at a prior proximal stent site • He had multiple co-morbidities including prior mantle radiation, myasthenia gravis, COPD, and PAF.

History • 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

SHY

Looks Like Something to Dilate

History • Continued to have unrelenting angina • Referred for 5 th opinion

Balloon Dilatation

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

Higher Pressure Cutting Balloon LASER Drill

Laser Bomb Failed 2 mm Burr Long Runs

3.5 NC 10 ATM

Post Dilatation

Follow Up • Angina free • Back to Work • EF 45% • Golfing

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

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.

How to Prevent Incomplete Revascularization? Do Both!

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