PCI: devil or angel? Repeated Stent Thrombosis after Emergency PCI Yu-Jie Zhou | MD, PhD Linlin Zhang | MD Beijing Anzhen Hospital

Basic Information Mr. Wang Male 56y Risk Factors Hypertension 10y Diabetes Mellitus 5y Smoking 20y Admitted in local hospital with “sudden serious chest pain”

Event Records st AMIAMI(Inferior, Posterior)1 st PCIPCI(RCA) 1 week later CAG LAD: Proximal-mid % RCA: Distal 100% Thrombosis in stent 2 nd PCISelected PCI(LAD)+ Repeated PCI(RCA) 1 hour after PCI 2 nd AMIAMI(Inferior, Posterior, extensive Anterior ) 3 rd PCIPTCA(LA D) Tirofiban reduction 3 rd AMIAMI(Anterior ) Tirofiban reduction 4 th AMIAMI(Extensive anterior )

1 st 1 st 1 st AMI(Inferior, Posterior) 1 st PCI CAG: Distal-RCA occlusion PCI:2.75*18mm stent in RCA

2 nd PCI( 2 nd PCI( Selected PCI) CAG: 60-85% in Proximal-mid LADPCI: 2.75*33mm,3.0*28mm in LAD

CAG: occlusion in a previously implanted stent in RCA PCI:2.5*24mm stent in RCA connected with previous stent 2 nd PCI( 2 nd PCI( Selected PCI)

2 nd 3 rd 2 nd AMI(Inferior, Anterior ) 3 rd PCI CAG: Occlusion in a previously implanted stent in RCA & LAD

nd 3 rd 2 nd AMI(Inferior, Anterior ) 3 rd PCI PTCA with LAD

Antithrombotic Therapy 1 st AMI 1 st PCI Regular treatment(Clopidogrel 600mg) 2 nd PCIAspirin + Clopidogrel + Tirofiban(7ml/h) + LMWH 2 nd AMITirofiban was adjusted to 14ml/h 3 rd PCI Injection from catheter: Tirofiban 20ml*2 UK 250,000u Aspirin + Clopidogrel (150mgQD)+ Tirofiban(14ml/h) + Heparin 3 rd AMI Aspirin(300mgBid) + Clopidogrel (150mgQD)+ Cilostazol (100mg Bid) Tirofiban(7ml/h) + Heparin 4 th AMIDitto

Clinical Reception Coronary Artery Disease Repeated AMI (Inferior, Posterior, extensive anterior ) Repeated Stent Thrombosis Pump Failure Hypertension Diabetes Mellitus

First Sight with Patient Condition in ANZHEN Hospital 感染： WBC 18.18G/L ；中性 90.9% ； 贫血： HGB107g/l ； 血小板减低： PLT 43.0G/L ； 急性心肌梗死： TnI 12.12ng/ml ； 肾功能不全： Cr 140umol/L ； BUN 13.9mmol/L ； 低蛋白血症：白蛋白 22.7g/L ； 心功能衰竭： UCG ：节段性室壁运动异常，左室舒张功能减低 ， EF25% ，室壁瘤形成（ 50*38mm ），巨大血栓（ 42*38mm ） ； ECG ：肢导低电压， V1-V5 导联呈 QS 型

Antithrombotic Strategy Probability of Revascularization

Stent Thrombosis is Multifactorial Lesion Long lesion Small diameter Multivessel AMI Diabetics Bifurcations Technical Underexpansion Incomplete wall apposition Crush technique Drug compliance Plavix withdrawal Drug Resistance Design Material composition Coating integrity Drug/Agents specific risks Antithrombotic treatments Patient Stent

Deterioration in patient Chest congestion Pink bubble sputum cough Dyspnea Hyoxemia Drop of blood pressure Coma Acute pulmonary edema Acute left heart failure Acute respiratory failure Acute cardiogenic shock

IABP ECMO Ventilator SIMV+Pressure Surport RR 8/min PEEP 6 FiO 40% Inspiration Pressure 4 Mve 3.6L Heart rate tracking 1 ： rev 3.5L/min Diuresis Sodium nitroprusside Dopamine

Therapeutic process 3 rd Day IABP 4 th Day Pump failure, Renal Failure, Respiratory Failure 5 th Day ECMO, Breathing machine Antithrombotic strategy Aspirin(100mgQd) + Ticagrelor(90mgBid)+ Tirofiban(5-2ml/h) + LMWH Wait for an opportunity with revascularization 10 th Day CAG+PTCA(ECMO+IABP)

Up-to-date PCI Up-to-date CAG: Recurrence Occlusion in a previously implanted stent Same as second AMI

Up-to-date PCI Up-to-date PTCA with LAD & RCA LAD: Tirofiban 10ml RCA: Tirofiban 6ml Thrombus aspiration: PCAB 3060

Discussion

2011 ACCF/AHA/SCAI Guideline for PCI Levine et al. Circulation Cardiogenic Shock: Recommendations

Developed with the special contribution of the European Association for Percutaneous Cardiovascular Interventions (EAPCI) et al. Eur Heart J 2010;31: Treatment algorithms for acute heart failure and cardiogenic shock.

PROsCONs IABP Improve Cardiac Output Reduce afterload Increase Coronary Perfusion Ease of Use Lower Complication rate over time Does not unload the heart Require a minimum of cardiac function Require a stable rhythm No proven benefit on mortality ECMO ECMO provides a temporary support in order to perform an invasive cardiac treatment (CABG or PCI), or to wait for heart transplant limited duration of 7 to 10 days, in particular due to hemorrhagic & hemolytic complications

The US Department of Justice (DoJ) is investigating AstraZeneca's PLATO trial of ticagrelor (Brilinta) October 31, 2013 Apparent Geographic Discrepancies in the trial- A trend toward worse outcomes at North American sites(1814 patients in the US and Canada, a primary end point occurring in 11.9% of ticagrelor-treated patients compared with 9.6% of those on clopidogrel, although the difference was not significant)

Ticagrelor Bests Clopidogrel for Reducing Stent-Thrombosis Risk: PLATO Published online July 30, 2013 in Circulation. "In the present subgroup analysis of the PLATO trial in patients with coronary stents, ticagrelor compared with clopidogrel reduced the incidence of stent thrombosis, regardless of the definition used" TicagrelorClopidogrel Definite stent thrombosis1.37%1.93%33% Definite or probable stent thrombosis 2.21%2.87%25%

Ticagrelor More Cardioprotective Than Clopidogrel December 31, 2012 online paper in Circulation At up to one year of follow-up, primary outcome events -- cardiovascular death, myocardial infarction, and stroke - had occurred in 1,057 ticagrelor patients and 1,225 clopidogrel patients (rate ratio=0.86, p=0.003) Stronger antiplatelet agent ticagrelor did a better job than clopidogrel (Plavix) in preventing not only the first heart attack, but also second or third ones -- including fatal ones."

Take Home Message Revascularization is still the key point for patient’s recovery PCI is the weapon, knowing how to use it is the only way we win the war with the disease IABP and ECMO are good assistant devices for doctors. Don’t hesitate to use them when necessary Individual antithrombotic strategy for your patients