PPCI – The Dark Side
Dr Geoff Richardson
PPCI Service
• Routine Standard Activations: – STEMI
– Rescues for high risk ACS
– Out of hospital cardiac arrest
– Shock states, IABP procedure
– Above elicit routine management responses
• Sometimes not quite so clear cut..
11/2/12
• 39 year old female
• Participating in high impact Tae Bo class
– total body fitness system that incorporates Martial Arts techniques such as kicks and punches
…and have a Coronary!
• 10 mins into exercise – left jaw/neck pain radiating to central chest & arms
• Crushing, 9/10 severity
• Worse on movement + deep breathing
• Ambulance called, GTN ineffective, Aspirin administered and admitted to DGH
DGH Assessment
• Admission 11:50
• HR 68bpm, BP 107/78mmHg
• Early BP fall to 75/41 responded to N saline
• EW risk score recorded as 1 due to hypotension
11:58am
DGH Clinical Records
• Inferior ST depression noted
• Time progresses • 12:55 Pain settled after Diamorphine, no response to
paracetamol
• Initial TnT 110 ng/L – Hb 136g/dl WCC 13.5, Plt 136 Urea 2.8 Chol 3.9, LDL
2.0mmol/l
• 13:45 Enoxaparin 60mg s.c and Clopidogrel 300mg
Risk Profiling
• Smoker 15/day, modest alcohol intake
• No hypertension or diabetes history
• Aunt with H/O HCM, grandmother IHD
• No regular meds, previous rx: Citalopram
• 4 healthy children
Clinical Progress in DGH
• 16:45 recurrence of chest pain requiring further Diamorphine
• Transfer to tertiary centre cath lab for PPCI
• First diagnostic angiogram 18:37
• Time delay approximately 12 hours from onset
First Diagnostic Image: JL4 5Fr
Diagnosis: Spontaneous Coronary Artery Dissection (SCAD)
• Infrequent occurrence
– 0.07% to 1.1% of all coronary angiograms
• True SCAD - dissection of intima/media + hematoma formation hallmark
• Younger patients, female preponderance • Association with peripartum or postpartum status • Case report associations connective tissue disorders, vasculitides,
and exercise
• Optimal treatment strategy undetermined • Favourable outcomes with:
– conservative management, fibrinolysis, PCI, CABG
• No comparative studies of treatment modalities
• From the Division of Cardiovascular Diseases and Division of BiomedicalStatistics and Informatics (R.J.L.), Mayo Clinic, Rochester, MN.
• objective of this retrospective study was to • evaluate the incidence, clinical characteristics, associations, and treatment
modalities of SCAD
• Key word screening of records 1979 –2011
• 508 potential patients
• analysis and coronary angiographic review excluded: – other diagnoses, iatrogenic coronary artery trauma,
and atherosclerotic plaque dissection
– angiographic definition of SCAD - presence of a dissection plane + absence of coronary atherosclerosis
• 87 patients with SCAD identified by angiography (2 IVUS)
Demographic Characteristics
• n = 87 • 71 (82%) female, 16 (28%) male • Mean age was 42.6 + 10 • Hypertension 18% • Diabetes mellitus 2.2% • Higher rates of hyperlipidaemia (31%) and
tobacco use (56%) in men
• Annual incidence of SCAD among residents of Olmsted County from 1979 to 2009
• 0.26 per 100 000 persons
• 0.33 women, 0.18 in men
• Potential causative associations in 48(55%) • Most common association in women was • Postpartum status (18%)
– mean maternal age 33yrs – mean postpartum period 38 days
• Hormonal therapy 11(15%) • Extreme physical activity was the principal precipitant in men
– (7) 44% versus (2) 2.8%. P<0.001
• Connective tissue disease in 7
– Ehlers-Danlos 1, Pseudoxanthoma elasticum 2 – Fibromuscular Dysplasia 10 female, 0 male
• Clinical Presentation • STEMI 49% • Non-STEMI in 44% • Unstable angina in 7% • 91% chest pain at presentation • 12 (14%) defibrillation for VF/VT • Angiographic Distribution • LAD most commonly affected • Multivessel in 20 patients (23%) • Fourteen (16%) 2-vessel • 5 (6%) 3-vessel
• LM 8(9%) • LAD 62(71%) • RCA 27(31%) • LCX 16(18%) • MV 20(23%)
Management?
• Optimal treatment strategy undetermined
• Reports have demonstrated favourable outcomes with: – Conservative management
– Fibrinolysis
– PCI
– CABG
• No comparative studies of treatment modalities
Question 1 What to do next?
a) Back to CCU, treat medically
b)Proceed to PCI
c) Refer for CABG
Guide Catheter + IC GTN
JL 3.5 6Fr Guide, BMW wire
BMW wire passed into true LAD lumen
Decompressing OMLCX Haematoma
Another Decision Point
Time to review the
Outcome data
Conservative Management
• Initial conservative strategy (31)
• uncomplicated in-hospital course
• 2 deaths on FUP
• angio repeated 13/31 @ mean of 40 months – in 4 for recurrent SCAD
• Of 17 initially dissected vessels: – 9 resolution or near resolution of dissection
– Partial resolution 3 of 17
PCI
• PCI procedure technically successful if any dilation was performed and any improvement in baseline TIMI grade 0 to 1
• or dilatation + maintenance/improvement of TIMI grade 2 to 3 flow • Flow - marker for success • Not improvement in lesion stenosis • Greater clinical relevance of flow in the acute situation + frequent
finding of residual dissection distinct from the dilated segment
• Successful procedures defined as complicated if > 2 additional stents placed for unanticipated propagation of dissection or hematoma during intervention
PCI Treatment Strategy
• 43 patients underwent PCI • technical success was achieved in 28 (65%) • • 7 of these successful 28 PCI procedures complicated
– (unanticipated propagation of the dissection flap or intramural haematoma requiring placement of >2 further stents)
• Reasons for failure in 15 PCI procedures (35%):
– failure to cross into the distal true lumen with a wire (n=9) – failure to cross the lesion with a balloon (n=1) – Propagation of dissection/hematoma during intervention with
reduction in final TIMI grade flow (n=5)
CABG
• 12 patients CABG – Index treatment strategy (n=4) – after fibrinolysis (n=3) – After unsuccessful PCI (n=5)
• LMS involved in 6 of the 12
• 1 in-hospital death – 51-year-old woman who presented with STEMI – LMS SCAD – TIMI grade 2 flow LAD + LCX – PCI attempted ,wire passage unsuccessful, hemodynamic instability, cardiac arrest – Emergency CABG was performed – multi-organ failure, died on post-op day 2
• 8 patients repeat angio • 15 grafts placed initially • 11 occluded • 5 LIMA – LAD • 1 RIMA – RCA • 5 SVG
Question 2 – What to do now?
a. Back to CCU, treat medically
b. Proceed to dilatation/ stenting
c. Refer for CABG
Decision: CABG
Follow-Up
• Patient fair at 1 year review
• Evidence of significant anterior wall damage
• Recurrent chest pain but non cardiac on imaging
• Undertaking regular light exercise
Follow-Up Data
• Median follow-up 47m • 15 (17%) experienced recurrent SCAD • 10-year SCAD recurrence rate was 29.4% • Median time to a second episode was 2.8 yrs
– (range, 3 days to 12 years)
• In 12 of 15, recurrence in previously unaffected coronary arteries • All 15 patients with SCAD recurrence were female • 10 year morbidity/ mortality:
– 5 heart failure – 16 myocardial infarction – 3 had died – observed 1- and 10-year mortality rates 1.1% and 7.7%, – 10-year rate for death, recurrent SCAD, AMI, and CHF - 47.4%
Thoughts on PCI
• PCI was associated with elevated rates of technical failure relating to
– passage of coronary wire into the false lumen
– loss of coronary flow through propagation of dissection and displacement of intramural hematoma by stent placement
Case 2: 46 yr old female 28/9/13 05:01
Wiring: Aim to achieve flow
Post balloon: TIMI 0 - 1
Stent TIMI 3
RAO post stent deployment
Question 3 Further Management
What would you do now?
a)Stop and continue with conservative Rx?
b)Further stent deployment to proximal LAD?
c) Refer for CABG?
Deterioration: Repeat Cath 29/9/13 01:21
Final Thoughts
• Limited data detailing natural history and no randomised trial data comparing different treatment modalities for SCAD
• Data support a conservative strategy in otherwise stable patients with normal flow in the affected coronary artery
• CABG as an initial strategy gives good short term outcomes however high rate of graft occlusion during follow up suggests that it may not provide long-term protection against effects of recurrent SCAD
Final Thoughts (2)
• PCI remains of critical role importance in the management of acute SCAD
• PCI - perhaps restrict to ongoing ischemia/ infarction given the relatively good early outcomes seen with initial conservative management
• Consider minimum intervention necessary to restore coronary flow – complications from SCAD intervention frequently related to the
placement of stents (with resulting propagation of hematoma)
• Peri-procedural adjunctive imaging IVUS/ OCT may provide better understanding of the SCAD plane/lumen(s) and guide intervention