Percutaneous Coronary Interventions for Patients with Relative Contra-indications: Severely Depressed Left Ventricular Function Great Wall International Conference on Cardiology. Beijing 11.5.2005 Thach Nguyen MD FACC FACP FSCAI

What is the most Common Cause of Death among Patients Undergoing PCI?

In Which Scenario I Will Do PCI Even The EF Is Low (<25%) ? 3

Scenario 1: AMI (EF<25%) Patient A: ST Segment Elevation. Heart Rate=70 and Blood Pressure 130/80 Patient B: ST Segment Elevation in Inferior leads, 2,3,F and V2R, V3R = RV MI HR:120 BP: 80/60. Mortality = ? Patient C: ST Segment Elevation in Anterior leads V1-V6. HR:120 BP: 80/50 How much is the mortality after PCI?

Scenario 2: Stable Angina (EF<25%) Patient has low EF however there is a large area of ischemia on Nuclear scan

What Do These 2 sets of Patients Have in Common?

What Do I Look When I Come To Evaluate a Patient with Very Low Ejection Fraction (<25%) For PCI ?

Evaluation of Patient with Very Low Ejection Fraction (<25%) before PCI 1. Does the Patient Have Frank Heart Failure ? 2. Does the Patient Have Moderate Mitral Regurgitation ? 3. Does the Patient Have Moderate Tricuspid Regurgitation ? 4. Is the Diagonal closed and/or a large Posterior Descending Artery from a dominant RCA or dominant Obtuse Marginal closed ?

Moderate Risk Patient (Ejection Fraction <25%) 1. Frank Heart Failure No 2. Mitral Regurgitation Mild 3. Diagonal or Posterior Descending Artery or Obtuse Marginal OPEN

Why I am Interested in Patency of PDA and Diagonal Branch? Right dominant RCA PDA Left dominant PDA LAD LCx LAO views

Scenario 3: Stable Angina (EF<25%) Patient has low EF and no other non-invasive data

Pre-Operative Evaluation? 1. Does the Patient Have Moderate Mitral Regurgitation ? 2. Does the Patient Have Moderate Tricuspid Regurgitation ? 3. Is the Diagonal closed and/or a large Posterior Descending Artery from a dominant RCA or dominant Obtuse Marginal closed ?

Moderate Risk Patient (Ejection Fraction <25%) 1. Frank Heart Failure No 2. Mitral Regurgitation Mild to moderate 3. Tricuspid Regurgitation Mild to moderate 4. Diagonal or Posterior Descending Artery or Obtuse Marginal OPEN

Which branch occlusion causes more mitral regurgitation? Research Question 1. Which branch occlusion causes more mitral regurgitation? The PDA to the posterior papillary muscle The Diagonal to the anterior papilary muscle

Research Question 2 2. Is mitral regurgitation a passive event secondary to left ventricular dilation or it is an important part of LV remodeling as programmed by intelligent design?

Scenario 4: Which One I refuse to Do? Dilated cardiomyopathy and frank heart failure

Scenario 4: Which One I refuse to Do? CLINICAL CRITERIA Severe dilated cardiomyopathy with Moderate to severe Mitral Regurgitation Moderate to severe Tricuspid Regurgitation Moderate to severe aortic regurgitation

Scenario 4: Which One I refuse to Do? HEMODYNAMIC CRITERIA Severe dilated cardiomyopathy with Elevated LVEDP Closed Diagonal and closed Posterior Descending Artery from either a dominant RCA or dominant Obtuse Marginal branch

Why ?

Research Question 3. 3. We can open and secure a good epicardial flow however, I strongly believe that the microvascular system is regulated more by receptors than by passive gradient between upstream and downstream pressure. In patients with diffuse triple vessel disease and severe LV dysfunction, the problem is not just flow disturbances and it is more suspected by inability of translation from energy brought by blood flow to contraction.

What Do I Look When I Come To Evaluate a Patient with Very Low Ejection Fraction (<25%) For PCI ?

When I Start the PCI, How I Know I am Getting into Trouble ? 1. Slow Rate of Rise 2. Widening of QRS THE PATIENT IS GOING INTO SHOCK

Check LVEDP and Rate of Rise

Conclusions

Conclusions: 1. What is the patient subset with highest mortality? 2. How to know which AMI patients will die in the near future? 3. Which patient has end-stage dilated cardiomyopathy who has high risk of mortality and no hope of recovery? 4. How to recognize a patient who is going into shock or in shock?