first-in-man prolonged pressure-controlled intermittent coronary sinus occlusion … ·...
TRANSCRIPT
First-in-man prolonged pressure-controlled intermittent coronary sinus occlusion to treat
refractory left ventricular dysfunction and ischemia
Francesco Giannini MD1, Marco Ancona MD1, Federico Pappalardo MD3, Luca
Ferri MD1, Richard J. Jabbour MD1, Andrea Aurelio MD1, Antonio Mangieri
MD1, Damiano Regazzoli MD1, Matteo Montorfano MD1, Michele De Bonis MD2,
Alberto Zangrillo MD3, Ottavio Alfieri MD2, Antonio Colombo MD1, Azeem
Latib MD1
1Interventional Cardiology Unit, 2Cardiac Surgery Unit and 3Department of Cardiothoracic
Anaesthesia and Intensive Care, San Raffaele Hospital, Milan, Italy
Disclosure Statement of Financial Interest
Speaker's name: Francesco Giannini
I do not have any potential conflict of interest
Clinical Scenario
• Patient Demographic: Male, 32-year-old
• Severe Aortic Regurgitation:
Bicuspid aortic valve
Normal ascending aorta
Dilated left ventricle; EF 48%
• Aortic valve repair: Free margin plication +
subvalvular annuloplasty
• Five hours after surgery:
Ventricular fibrillation
Cardiogenic shock
Treatment
• Peripheral VA-ECMO
• IAOBP
Emergency re-sternotomy
Coronary Angiography
Spasm on mid LAD and RCA
TT Echocardiography
Clinical Scenario
• 1st Post operative (PO) day:
Impella placement due to poor LV unload
IAOBP removed
• 1st to 15th PO day:
Full mechanical support with VA-ECMO and
Impella
No LV function recovery
ECG: diffuse ST-segment depression
• 15th PO day: Repeated coronary angiography
Coronary Angiography - 15th PO day
Persistence of spasm on LAD
Baseline After nitrate
Spasm on RCA resolved
TT Echocardiography – 15th PO day
What shall we do?
• Full mechanical support (ECMO + Impella)
since 15 days
• Persistence of refractory LV dysfunction:
Diffuse ST-segment depression
• PICSO?
Percutaneous Intermittent Coronary Sinus
Occlusion (PICSO)
Van de Hoef TP et al.; EuroIntervention. 2015 May 19;11(1):37-44
• Prepare RAMSES study: 30 STEMI patients
• Primary end-point
Safety and feasibility of 90 minutes of PICSO treatment after pPCI
CMR-defined infarct size at 2-5 days and 4 months post pPCI for
PICSO-treated versus matched control patients
Percutaneous Intermittent Coronary Sinus
Occlusion (PICSO)
- PICSO Impulse Catheter
- PICSO Impulse Console
Percutaneous Intermittent Coronary Sinus
Occlusion (PICSO)
Intermittent occlusion of the coronary sinus
increases coronary sinus pressure which
translates into an increase in (arterial) wedge
pressure over the ischemic area
This leads to:
I. Redistribution of venous blood to the
border zone of the deprived
myocardium1
II. Enhanced washout of deleterious
agents from the microcirculation2
III. Induction and expression of VEGF in
the ischemic myocardium from the
venous endothelium3,4
1. Ido A, et al., Am J Physiol Heart Circ Physiol 280:1361-1367, 2001 2. Ikeoka et al.Jpn Circ J Oct;54(10):1258-73, 19903. Weigel G, et al., J Thorac urg 2007;133 4. Mohl W, et al., Nat Clin Pract Cardiovasc Med 2008;5:528-05. Mohl W, et al., Am J Cardiol 1984 Mar 15;53(7):923-8
PICSO: Novel Indication
Prolonged PICSO treatment
PICSO placed on 16th day
PICSO results
Recovery of normal LV function the day after PICSO
Prolonged PICSO therapy (17th – 20th PO day)
- PICSO quantity: 24829 mmHh
20th PO day: weaning from ventricular assistance device
- Sepsis and Respiratory failure
Conclusions
• Standard PICSO treatment:
To reduce the extend of myocardial necrosis in
STEMI patients
Maximum 90 minutes
• Novel application: prolonged PICSO therapy
To treat refractory LV dysfunction and ongoing
ischemia
Efficacy probable related to redistribution of
venous blood and improvement in
microvascular perfusion
Thank for your attention