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Patients with complex coronary artery disease and acute coronary syndrome. Current treatments.

Explore current treatments and evolving frontiers in the management of complex coronary artery disease and acute coronary syndrome. Learn about patterns of coronary artery disease in NSTEMI and the optimal timing of invasive angiography. Considerations for left main patients and the use of unprotected left main stenting are also discussed.

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Patients with complex coronary artery disease and acute coronary syndrome. Current treatments.

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  1. Patients with complex coronary artery disease and acute coronary syndrome. Current treatments. Ioannis Iakovou, MD, PhD Associate Director Interventional Cardiology Onassis Cardiac Surgery Center

  2. The evolving management of ACS Alfonso, et al JACC Intv 2010;3:32-34

  3. The evolving management of ACS • EVOLVING FRONTIERS IN COMPLEX PCI IN ACS PTs • Bifurcation disease (including Unprotected LMCA). • Multivessel disease • Complete vs incomplete revascularization . • Transradial approach • Miscellaneous new tools

  4. ACS Atherosclerotic Plaque Ino et al JACC Interv 2011

  5. Pattern of coronary artery disease in NSTEMI • In contrast to STEMI, determining the culprit artery in NSTEMI is not always feasible in all patients • A coronary lesion should be considered culprit if it fulfills at least two of the following criteria: • intraluminal filing defect (thrombus) • plaque ulceration, • plaque irregularity • dissection or impaired flow

  6. Pattern of coronary artery disease in NSTEMI • Up to 20% of patients with NSTE-ACS have no lesions or nonobstructive lesions of epicardial coronary arteries • Patients with obstructive CAD, 40 – 80% have multivessel disease • LAD coronary artery is the most frequent culprit vessel in both STEMI and NSTEMI-ACS (in up to 40% of patients) • Regarding the distribution within the infarct-related artery, culprit lesions in NSTE- ACS are more often located within the proximal and mid segments (3-8% LM) Mehta SR et. al ,. Early versus delayed invasive inter- vention in acute coronary syndromes. N Engl J Med 2009;360:2165–2175. Thiele H et. al, , Optimal timing of invasive angiography in stable non-ST-elevation myocardial infarction: the Leipzig immediate versus early and late PercutaneouS coronary intervention triAl in NSTEMI (LIPSIA-NSTEMI trial). Eur Heart J 2012;33:2035–2043. Ndrepepa G,et al . Patterns of presentation and outcomes of patients with acute coronary syndromes. Cardiology 2009;113:198–206. KerenskyRA, et al, Revisitingtheculprit lesion in non-Q-wave myocardial infarction. Results from the VANQWISH trial angiographic core laboratory. J Am Coll Cardiol 2002;39:1456–1463

  7. Which Left Main Patients Should Go For CABG? • Is the SYNTAX score very high? • Can we achieve complete revascularization? § Is revascularization of an occluded RCA important in this patient? • Is the patient a diabetic? • Is the left main heavily calcified, and tortuous with good distal targets for bypass grafting? • Do co-morbid considerations make the patient a poor candidate for CABG?

  8. Left main coronary artery stenosis as a culprit lesion in the acute coronary syndromes PCI should be preferred in the presence of the following clinical features – Cardiogenic shock – Initial TIMI 1/0 flow – Isolated LMCA culprit lesion – Poor surgical candidate (high euroSCORE, distal coronary disease unfavorable to CABG or co-morbidity, including chronic obstructive lung disease and renal failure) – Favorable anatomy providing complete revascularization (low or intermediate SYNTAX score) – Patients with rudimentary circumflex artery

  9. Unprotected Left Main Stenting • UPLM stenting is a “staple” for CHIP operators • • Learn the many caveats: • Thoughtful case selection =/- heart team • Cardiac Support • Bifurcation stenting • Imaging • • Practice! • • Practice! • • Practice!

  10. LM case 1 83 year old, female with unstable angina and porcelain aorta

  11. LM case 1 83 year old, female with unstable angina and porcelain aorta, PCI RRAD, 6Fr StentLAD prox IVUS guided 2 stent technique: step Cullote POT, KBI, RePOT

  12. LM case 1 83 year old, female with unstable angina and porcelain aorta, PCI RRAD, 6Fr

  13. Q & AAPLT 83 year old, female with unstable angina and porcelain aorta undergoing PCI. Which of the following is false? • Radial access is recommended over femoral, if performed by an experienced radial operator. • Aspirin in the dose of 325 mg is recommended on top of an P2Y12 agent. • Proton pump inhibitors (PPI) are recommended in patients on DAPT, since gastrointestinal bleeding accounts for a big portion of bleeding complications. • Routine platelet function testing is not recommended, due to it not being reliably associated with clinical outcomes.

  14. Q & AAPLT 83 year old, female with unstable angina and porcelain aorta undergoing PCI. Which of the following is false? • Radial access is recommended over femoral, if performed by an experienced radial operator. • Aspirin in the dose of 325 mg is recommended on top of an P2Y12 agent. • Proton pump inhibitors (PPI) are recommended in patients on DAPT, since gastrointestinal bleeding accounts for a big portion of bleeding complications. • Routine platelet function testing is not recommended, due to it not being reliably associated with clinical outcomes.

  15. Left main coronary artery stenosis as a non-culprit lesion in acute coronary syndromes • Concurrent LMCA and non-LMCA PCI has worse outcomes than isolated LMCA PCI • it is logical to postpone LMCA revascularization if the culprit lesion is located in the right coronary artery (RCA). • PCI of culprit lesion located either in LAD or CX in the presence of significant LMCA lesion is a hazardous clinical issue and may necessitate concurrent LMCA intervention. • Short and long-term data on simultaneous PCI of LMCA and non-LMCA culprit vessel are not well-defined.  Pedrazzini G.B JACC Interv 2011

  16. Unprotected Left Main Caveats: • Don’t stent Pseudo ostial LM stenses

  17. LM case 2 63, year old male Pt with unstable angina New coro 1mo later

  18. LM case 2 63, year old male Pt with unstable angina PCI –stent @LAD pox & mid, abolition of spasm with ic nitrates 9.89mm2 10.9mm2

  19. LM case 2 63, year old male Pt with unstable angina PCI –stent @LAD pox & mid, abolition of spasm with ic nitrates

  20. LM case 3 66, year old male Pt with unstable angina Pt was refer to CABG

  21. LM case 3 66, year old male Pt with unstable angina IVUS Findingsreverse tapering of the LM, distal EEM CSA 12.36 mm2 MLA:7.2 mm2, proximal EEM CSA 9.3 mm2 MLA:6.9 mm2,

  22. LM case 3 66, year old male Pt with unstable angina

  23. Left main coronary artery stenosis as a culprit lesion in the acute coronary syndromes CABG is a preferred option: – Concomitant valvular disease or mechanical complication – Heavy calcified LMCA disease – Multi-vessel disease with high SYNTAX score – Reduced left ventricular function – Diabetic patients.

  24. ACS with LM

  25. Potential Consequences of Multivessel InterventionDuring PPCI • Favorable • Ensuring adequate, complete, early revascularization • Revascularization of remote ischemic myocardial territory • Lower requirement of repeated procedures • Improvement of left ventricular function • Stabilization of additional disrupted plaques • Reduction of hospital stay • Reduction in hospital costs • Improving long-term clinical outcome (?) • Unfavorable • Prolonged procedures • Larger amount of contrast media (heart failure, renal failure) • Concerns of jeopardizing remote but critical myocardium in the acute phase • Higher rates of procedure-related myocardial infarction • Higher requirement of late procedures as the result of restenosis from • multivessel stenting • Inaccurate assessment of lesion severity/revascularization requirements • Shadowing in-hospital and long-term prognosis (?)

  26. STEMI and MVD

  27. NSTEMI with multivessel disease:when and how to treat the “non culprit”lesions? Qiaio et al. EuroIntervention. 2015 ;11(5):525-32.

  28. One vs. 2-stages PCI in MVD J Am Coll Cardiol 2016;67:264–72

  29. Timing of Complete RevascularizationDuring ACS

  30. Complete Revascularization in NSTEMI + MVD

  31. Comparison of MACE in FAME patients with andwithout ACS

  32. MV disease PCI 53 y, male heavy smoker with cardiogenic shock

  33. MV disease PCI 53 y, male heavy smoker with cardiogenic shock @ 10 mos FU pt is asymptomatic, Echo: FE: 50-55%

  34. Conclusions • In the setting of acute coronary syndromes, percutaneous intervention of unprotected LMCA lesions can be performed with reliable results in selected patients. • In MV CAD, PCI has an important role in ACS. • Concurrent LMCA and non-LMCA culprit vessel intervention can also be performed securely with good long-term results in selected patients • Surgery can be selected for stable patients with multi-vessel disease and/or higher SYNTAX score. • Cardiogenic shock and hemodynamic instability are obligatory indications for PCI, although associated major adverse cardiac events are more frequent.

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