Download PCI versus CABG

缺血性心力衰竭介入治疗策
略
PCI strategies for patients with ischemic
heart failure
哈尔滨医科大学附属第一医院
李为民
The First Affiliated Hospital Of Harbin
Medical University
 Ischemic heart disease is a major health problem
worldwide and will eventually progress to heart failure,
which is termed as ischemic heart failure (IHF)
 Patients with IHF suffer from high rates of ischemic
events, arrhythmic events, and mortality
Sardi GL. Am J Cardiol 2012;109:344–351
 Despite advances in medical treatment, current
therapeutic approaches to IHF remain very limited
 Revascularization in IHF patients has been proven to
recruit hibernating or stunned myocardium in an effort to
improve overall myocardial contractility
缺血性心脏病患者如出现心衰症状及体征，
建议评估患者是否需行冠脉造影以明确病
变程度！
心衰患者如伴心绞痛症状且适合行血运重建治
疗，建议先行冠脉造影以明确病变程度!
European Heart Journal (2012) 33, 1787–1847
PCI versus CABG
 The choice of PCI or CABG in IHF
patients is uncertain due to the fact
that most studies comparing PCI
and CABG in patients with CAD
have excluded patients who have
significant ventricular dysfunction
对不适合行CABG的伴左主干或多支病变的
IHF患者，PCI可成为替代的血运重建方式！
PCI versus CABG
 A meta-analysis of studies utilizing PCI among patients with
IHF was performed to determine in-hospital and long-term
mortality
 In total, 4766 patients from 19 studies were included in this
meta-analysis. The in-hospital mortality was 1.8% and the
long-term mortality (24 months) was 15.6%. Five studies
compared PCI versus CABG and resulted in similar longterm mortality with relative risk of 0.98
Coronary Artery Disease 2012, 23:469–479
In-hospital mortality
Long-term mortality
Coronary Artery Disease 2012, 23:469–479
PCI versus CABG
Meta-analysis in IHF patients
Total patients: 957
Coronary Artery Disease 2012, 23:469–479
PCI versus CABG
 The present meta-analysis demonstrates that on the basis of
available clinical studies, PCI among patients with left
ventricular systolic dysfunction is feasible with acceptable in-
hospital and long-term mortality and yields similar outcomes
to CABG.
Coronary Artery Disease 2012, 23:469–479
Complete vs. Incomplete
Revascularization by PCI
 IHF patients often have multi-vessel disease, leading to a
controversy of complete versus incomplete revascularization
Definition of CR and ICR
ACUITY Angiographic Substudy
One-year MACE（2954 NSTEACS）
Rosner G et al. Circulation 2012
ACUITY Angiographic Substudy
One-year MACE
Rosner G et al. Circulation 2012
CR VS IR in patients without STEMI
Three-year follow up (n=873)
Song YB et al. Heart vessels, 2012
CR VS IR in patients with stable MV
10-year follow up（n=408）
Vieira RD, et al. Circulation, 2012
 There is a clear trend towards the better outcomes with
complete revascularization than with incomplete
revascularization,
 Interventional cardiologists should make the result as
‘‘CABG-like’’ as possible, and this includes attempted
revascularization of CTO
Edward L. J Am Coll Cardiol Intv, 2009, 2:17
Staged PCI is preferred in the following
situations:
 STEMI with multivessel disease
 Unsatisfying results or acute occlusion；
 Complex lesions, e.g. CTO lesions；
 Longer procedure time or patient intolerance；
 Over-use of contrast agent；
Staged
PCI
 Elderly patients；
 Severe cardiac or kidney dysfunction；
 Two or more lesions supplying large areas；
Pros and Cons of staged PCI
 Complete revascularization

Increased medical costs
 Reduced single procedure time

Treatment of asymptomatic
and contrast agent
 Lower incidence of heart failure
and CIN
 Correction of in-stent restenosis
from initial PCI
lesions

Uncertain timing of staged
PCI
Use of percutaneous circulatory
support devices
IABP
TandemHeart
ECMO
Impella
Percutaneous circulatory support devices are beneficial
for short-term use to stabilize IHF patients undergoing
PCI or as “bridges” to cardiac transplantation
Combination of PCI and CRT
in IHF patients
PCI
×
Coronary
occlusion
×
Ventricular
remodeling
Acute ischemic
heart disease
Hibernating
or stunned
myocardium
Chronic ischemic
heart disease
Ventricular
dyssynchronization
×
CRT
Inclusion criteria
 Patients with IHF (n=7)
 NYHA Ⅲ～ Ⅳ级
 QRS  130 ms
 LVEF  0.4
 LVEDD  55 mm
Right Atrial
Lead
Left Ventricular
Lead
Right Ventricular
Lead
 Optimal medication
Yaling Han. Chinese Journal of Cardiology, 2005, 33:17
 For IHF patients with indication for both PCI and CRT,
the combination of PCI and CRT could improve their
cardiac function, quality of life, and prognosis
 The underlying mechanism and long-term efficacy of the
combined therapy needs to be further exploited
Yaling Han. Chinese Journal of Cardiology, 2005, 33:17
Stem-cell therapy for IHF
 Limitations of current therapies have led to research
aimed at regenerating and repairing ischemically damaged
myocardium through stem-cell therapy
Still Controversial
Stem-cell therapy for IHF is very promising.
However, major issues still need to be resolved.
 To test and confirm the most beneficial subpopulations of
autologous stem cells
 To identify the optimal dosage and timing of cell therapeutics
To produce optimum cell delivery and homing capacity
To explain and explore the mechanisms of cell therapy in
humans (paracrine or myocardial regeneration or both)
Case 1
 A 78-year-old woman presented with chest pain
lasting for 3 h
 Hypertension for 10 years
 BP: 80/50 mmHg
 CK-MB: 48 u/L; TNI: 11.75ng/ml; TC: 5.98 mmol/L
 LVEF: 35 %
ECG
Total occlusion
of LCX
A 99% stenosis
In proximal RCA
Conservative therapy, Immediate CABG or PCI
SHOCK Trial
In the SHOCK trial, at a median follow-up of 6 years, survival in the early
revascularization group was 32.8%, compared with 19.6% for the initial medical
stabilization group in AMI complicating cardiogenic shock（CS）
J.S. Hochman, JAMA, 2006, 295 : 2511–2515.
Strategy----- Revascularization
×
Conservative therapy, Immediate CABG and PCI
Which one is better
?

Available data from 4 observational reports suggest
similar mortality rates with CABG and PCI in patients
with AMI and multivessel coronary disease complicated
by CS
Mehta RH. Am Heart J. 2010 Jan;159(1):141-7.
Strategy ------ PCI
Incomplete or complete revascularization
?
急诊PCI时，如患者伴严重血流动力学障碍，
可一次性处理多支病变！
Strategy------ Multi-vessel intervention
LCX or RCA
Which one should be treated first
?
IABP and temporary pacemaker
JR4.0
Runthrough
Sapphire 2.0×15mm
（10 atm）
Excel 2.75×18mm
（12 atm）
BL3.0
Runthrough
Export Aspiration
Sapphire 2.0×15mm
（12 atm）
Final result
Excel 2.75×33mm
（12 atm）
Take home message

In AMI patients complicated by CS, multi-vessel PCI may
protect ventricular function and improve survival rate

The use of IABP seems to be extremely important to
maintain hemodynamic stability in AMI patients with CS
 Aspiration
devices should be applied in patients with a large
thrombus burden
Case 2
 A 59-year-old male patient presented with exertional
chest tightness for 8 years
 The patient had hypertension and diabetes for more
than 10 years and underwent CABG 8 years ago
 ECG: Pathological Q waves in leads II, III, and avF
 LVEF: 32%
Occlusion in
distal segments
of LAD and OM
Subocclusion
of distal RCA
Patency of
IMA-LAD graft
Multiple
stenosis of
SVG-OM
A 99% stenosis
of SVG-Diagonal
Multiple stenosis
of SVG-PL
2.5×20mm
Voyager balloon
(8 atm)
Final result
Take home message
 Over 50% of SVGs are occluded 10 years after CABG,
whereas the patency rate of IMA is about 90%
 In patients with occluded SVGs, the preferred strategy is
to treat the de novo native coronary artery
Case 3
 49岁，男，因“持续性胸痛8小时”入院
。
 查体：BP：150/120mmHg,P:120次/分。
端坐体位，双肺可闻及湿罗音，心音弱，
HR:120次/分，腹软，双下肢无浮肿。
 心电示：V1-V5 ST段弓背向上抬高；心
脏彩超：前壁节段性运动异常，
LVED:64mm,EF:25%；TNT:+
 诊断：急性前壁心肌梗死
急性左心衰
 治疗：患者拒绝溶栓或介入治疗。经
充分抗凝、抗血小板及纠正心功能治
疗（阿司匹林，氯吡格雷，依诺肝素
，硝普钠，速尿，重组人脑利钠肽 ，
硬膜外阻滞）。
 病人反复发生心绞痛、心衰，
始终无法平卧。
 UCG:LVED 75 mm
EF:28%。
？
反复沟通，入院
后第25天，患者
同意介入治疗。
前降支近中段自发
性夹层70%狭窄
 行PCI后，患者症状明显改善，可以平卧，无心绞痛
，心衰症状发作。
 4W后复查彩超：LVED：67mm, EF:30%
 11W后复查彩超：LVED：65mm
,EF: 38%
明确心力衰竭的病因并针对
病因进行治疗，尤为重要！
症状明显改善，缓解出院······
Case 4
 A 78-year-old male patient presented with exertional
chest pain for 3 months
 The patient had hypertension for more than 10 years
 ECG: ST depression in leads Ⅰ、avL、 V2-6
 Echo: LV diameter: 67mm, LVEF: 33%
CAG
BL3.0
Runthrough
Resolute
3.0×24mm
Ryujin
2.0×15mm
Ryujin
1.5×15mm
Ryujin
2.0×15mm
XINCE V
2.25×23mm
 Pro-PCI—Echo: LV diameter: 67mm, LVEF: 33%
 1 week Post-PCI—Echo: LV diameter: 61mm, LVEF: 37%
Take home message
 PCI among patients with stable angina and left
ventricular systolic dysfunction(EF≤40%) is feasible with
acceptable in-hospital outcomes
 Complete or nearly complete revascularization is the
optimal strategy
 Target vessel related with Large area of myocardial
ischemia is the first choice for PCI
Revascularization is an
unyielding principle for
IHF patients!