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