My Best Radial Case of the Past Year ... And what I learned from it CRT 2017 February 20, 2017

Disclosures Consulting: Research Grants: Terumo Interventional Systems Boston Scientific Medtronic Acist Medical Research Grants: Edwards LifeSciences Abbott

Case Presentation 67 year old male No significant PMH Called EMS with chest pain of 1 hour duration Cardiac arrest essentially as EMS arrived ACLS per protocol Initial rhythm VF Shocked with ROSC Intubated in field ECG with inferior ST-elevation Field activated STEMI Taken straight to Cath Lab on arrival Hemodynamically stable, Killip Class 2 Modified Allen’s Normal – yes, we still check

STEMI - Prep

6F Access – IL 3.5 Guide System connected from beginning 0.035” J-wire left in guide catheter Pulled back a few inches for left coronary system I still prefer contralateral first approach

6F Access – IL 3.5 Guide Advance J-wire almost to guide tip for RCA Will leave in place until 0.014” wire down Convert passive support to active support

Standard STEMI Management

STEMI – Primary PCI

Inferior STEMI (field activated) Times: Symptoms to EMS – 60 minutes EMS to Door – 32 minutes Door to Cath Lab – 5 minutes Cath lab to Access time – 9 minutes Access to Device time – 12 minutes Metrics: Door to Device time – 24 minutes EMS to Device time – 56 minutes

Post Cath Course Taken to CVICU upon case completion Targeted Temperature Management Post STEMI care No residual defects Discharged on hospital day # 5. Seen in clinic for follow-up …

Why this case . . . Was this really my “best case”??? No. Transradial STEMI is routine in our lab. The RCA was straightforward. It’s a good result, but nothing special Was this my best ”learning experience” In full disclosure: I’ve been totally schooled over the past year. I tend to remember and learn from negatives.

We can Learn from Positives as well This is access, not religion. Bleeding reduction is a good thing. Coaxial guide engagement is what matters. We are here to treat patients. Excepts from past conferences.

RIFLE STEACS 30-day MACE rate p = 0.02 p = 1.00 p = 0.6 p = 0.73 Romagnoli et al. J Am Coll Cardiol 2012 60 2481 13

RIFLE STEACS 30-day NACE predictors OR CI 95% p value Female gender 1.5 (1.1-2.3) 0.037 CKD 2.1 (1.4-3.1) 0.001 Radial access 0.6 (0.4-0.9) 0.012 Killip class 1.8 (1.5-2.2) LAD culprit 1.7 (1.2-2.6) 0.006 TIMI 0 basal 1.4 (1.0-2.1) 0.073 LVEF <50% 1.6 (1.1-2.5) 0.025 TIMI 0-1 final 2.4 (1.1-5.1) 0.024 p= 0.002 Romagnoli et al. J Am Coll Cardiol 2012 60 2481

NCDR CathPCI Registry Access Trends STEMI 2007-2011 (n=90,879) Baklanov et al. J Am Coll Cardiol. 2013 61 420

NCDR CathPCI Registry STEMI 2007-2011 (n=90,879) Baklanov et al. J Am Coll Cardiol. 2013 61 420

Conclusions We can learn from all experiences Positive and negative The work that we do really does translate back to the patient

Thank You