PCI for STEMI: Fix the Culprit Lesion, or Fix All of James James Hermiller Hermiller, MD, FACC, FSCAI , MD, FACC, FSCAI St Vincent Medical Group St Vincent Medical Group St Vincent Heart Center of Indiana St Vincent Heart Center of Indiana Indianapolis, IN Indianapolis, IN Culprit Lesion, or Fix All of the Lesions
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PCI for STEMI: Fix theCulprit Lesion, or Fix All of
JamesJames HermillerHermiller, MD, FACC, FSCAI, MD, FACC, FSCAISt Vincent Medical GroupSt Vincent Medical Group
St Vincent Heart Center of IndianaSt Vincent Heart Center of IndianaIndianapolis, INIndianapolis, IN
Culprit Lesion, or Fix All ofthe Lesions
Disclosure Statement of Financial Interest
• Grant/Research Support
• Consulting Fees/Honoraria
• Edwards, Medtronic, Abbott, StJude, BSC
• Edwards, Medtronic, Abbott, StJude, BSC
Within the past 12 months, I or my spouse/partner have had a financialWithin the past 12 months, I or my spouse/partner have had a financialinterest/arrangement or affiliation with the organization(s) listed below.interest/arrangement or affiliation with the organization(s) listed below.
Multivessel coronary disease diagnosed at the timeof primary PCI for STEMI: complete
revascularization versus conservative strategy.PRAGUE 13 trial
O. HlinomazO. HlinomazICRC, St. Anne University Hospital, Brno, Czech Republic
On behalf of the PRAGUE-13 Investigators
L. Groch, K. Polokova, F. Lehar, T. Vekov, R. Petkov, M. Stoynev, M. Griva, J. Sitar, M. Rezek,M. Novak, J. Semenka, N. Penkov, B. Gersh, D. Holmes, G. Sandhu, P. Widimsky
Grant IGA Czech Republic NT11412-5/2010, VAVPI EU ProjectNCT01332591
EuroPCR 2015
214 STEMI patients
Randomized following infarct-related artery (IRA)-PCI:
Complete revascularization (n=106)
IRA -only PCI (n=108)
Complete revascularization performed as a staged
PRAGUE-13 Trial
Complete revascularization performed as a stagedprocedure
Conclusions: Complete revascularization of all significantcoronary lesions at the time of primary PCI was associatedwith a reduction in the risk of MACE due to reduction in therisk of urgent re- vascularization. This approach appears to besafe, with no excess major bleeding, or contrast-inducednephropathy.
Complete revasc associated withlower incidence of MI or mortality
Complete revasc associated withhigher incidence of MI or mortality
Contrast dose in CO vs MV PPCI:Increased Risk of CI-AKI
CO (cc) MV (cc) P value
PRAMI 200 (150-260) 300 (210-380) < 0.001
CVLPRIT 190 (150-250) 250 (190-330) < 0.0001
Wald DS, et al. N Engl J Med 2013;369:1115-23.Gershlick AH, et al. J Am Coll Cardiol 2016;65:963-72
Gurm, HS et al. J Am Coll Cardiol 2011;58:907-914
Overestimation of Non-Culprit StenosisSeverity in Setting of STEMI (n=122)
PPCI (n=507)
Only culprit-lesionPCI indicated (n=374
[74%])
Non-culprit lesion f/uindicated (n=122
[24%])
Complete MV PCI(n=11 [2%])
Thim T, et al. Open Heart 2016;3:000427
[74%]) [24%])
3 died
3 LTFU
Non-culprit lesion f/uperformed (n=116)
Revasc not
[33.6%])
Revasc notindicated (n=39
[33.6%])
PCI indicated(n=58 [50%])
CABG indicated(n=19 [16.4%])
Overestimation of Non-Culprit StenosisSeverity in STEMI (n=81)
Donmez E, et al. Int J Cardiovasc Imaging 2016;32:1471-1476
’Critically narrowed’ non–culprit arteries at time of PPCIdeemed ‘non-critical’ during control coronary angiography in
13.3%
Outline
• Introduction
• The DATA
• Randomized Trials• Randomized Trials
• Guidelines
• Future Studies
• Summary
Levine, et al. JACC. 2016:67; 125-1250.
Outline
• Introduction
• The DATA
• Randomized Trials• Randomized Trials
• Guidelines
• Future Studies
• Summary
The Ongoing Trialsn ImmediateStrategy
SubsequentStrategy
for UntreatedNon-Culprit
Lesions
FFRStrategy
COMPARE-ACUTE
800 Culprit Only vsFFR GuidedComplete
“GuidelineBased” PCI in
CulpritOnly Group
DS > 50% - FFR(blinded inculprit only
group)
COMPLETE
3000 Culprit OnlyIn Both Groups
Staged CompleteRevasc (PCI)
Within 6 weeks
DS 50-70% - FFRDS > 70% - Stent
FULLREVASC
4052 Culprit Only vsFFR Guided
Complete DuringIndex Admission
(Immediate orStaged)
“PRAMI”CONTROL
Symptom orischaemia drivenrevasc only. No
mandatoryischaemia testing
DS 50-90% - FFRDS > 90% - Stent
Key Points• Despite current guidelines, there is expanding evidence for the safety
and efficacy of routine multivessel PCI for STEMI patients.• FFR has incremental value for assessing stenosis severity in STEMI
patients with multivessel disease.• Further studies of vulnerable plaque are needed to obtain a complete
risk assessment in STEMI patients.
Outline
• Introduction
• The DATA
• Randomized Trials• Randomized Trials
• Guidelines
• Future Studies
• Summary
Summary
•• The optimal time for completeThe optimal time for complete revascrevasc….….
•• Immediate?Immediate? Staged duringStaged during index?index? Staged a fewStaged a fewdays/weeksdays/weeks later?later?
•• ShouldShould we targetwe target ischemicischemic lesions only using FFR?lesions only using FFR?
•• InIn other situations FFRother situations FFR--guidedguided revascrevasc isisassociated with a better outcomeassociated with a better outcome andandassociated with a better outcomeassociated with a better outcome andand
•• PCIPCI on nonon non--ischaemic lesions has an adverseischaemic lesions has an adverseoutcomeoutcome……
•• Is the real world population so different from theIs the real world population so different from thecarefully selectedcarefully selected groups ingroups in the RCTs that it isthe RCTs that it isimpossible to extrapolateimpossible to extrapolate to real practice?to real practice?
Conclusion
• In patients with STEMI and MVD, there isinsufficient evidence to support areduction in death/MI long-term with multi-vessel PCI
• Await the results of larger RCTs before• Await the results of larger RCTs beforemaking any definitive conclusionsregarding optimal revascularizationstrategy
• For now, PCI is acceptable in selectedpatients (FFR directed at time of staged?)– IIb indication
Case Review
Stented RCA
It’s 2AM --It’s 2AM -- FFR LADFFR LAD
Case Review
FFR LAD
Case ReviewLAD Undilatable – Rota/Stent Prior to
Discharge
Thanks for your attention!Thanks for your attention!