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！

European Heart Journal (2012) 33, 1787–1847 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 !

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！

 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 long- term mortality with relative risk of 0.98 PCI versus CABG Coronary Artery Disease 2012, 23:469–479

In-hospital mortality Long-term mortality

PCI versus CABG Meta-analysis in IHF patients Total patients: 957 Coronary Artery Disease 2012, 23:469–479

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 PCI versus CABG

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 ；  Elderly patients ；  Severe cardiac or kidney dysfunction ；  Two or more lesions supplying large areas ； Staged PCI

Pros and Cons of staged PCI  Complete revascularization  Reduced single procedure time and contrast agent  Lower incidence of heart failure and CIN  Correction of in-stent restenosis from initial PCI Increased medical costs Treatment of asymptomatic lesions Uncertain timing of staged PCI

Use of percutaneous circulatory support devices ECMO IABPTandemHeart Impella

Percutaneous circulatory support devices are beneficial for short-term use to stabilize IHF patients undergoing PCI or as “bridges” to cardiac transplantation

PCI Combination of PCI and CRT in IHF patients CRT Acute ischemic heart disease × × Ventricular remodeling Ventricular dyssynchronization Coronary occlusion Chronic ischemic heart disease × Hibernating or stunned myocardium

Inclusion criteria Patients with IHF (n=7) NYHA Ⅲ～ Ⅳ级 QRS  130 ms LVEF  0.4 LVEDD  55 mm Optimal medication Yaling Han. Chinese Journal of Cardiology, 2005, 33:17 Right Atrial Lead Right Ventricular Lead Left Ventricular Lead

 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

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. SHOCK Trial

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 Jan;159(1):141-7.

Incomplete or complete revascularization Strategy PCI ?

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 Which one should be treated first LCX or RCA ?

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

 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 Take home message

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% 症状明显改善，缓解出院 ······ 明确心力衰竭的病因并针对 病因进行治疗，尤为重要！

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 、 V 2-6  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%

 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 Take home message

Revascularization is an unyielding principle for IHF patients!