1. Sameer Mehta, MD, FACC, MBA Course Director, Lumen www.stemiinterventions.com www.lumenami.com

2. Conflict of Interest Statement  No conflict of interest or disclosure  SINCERE database remains independent and is not conflicted by any financial support

3. “Process” & “Procedure” of STEMI Interventions

4. “You cannot travel on the path until you become the path itself”

5. SINCERE LOGISTICS 1 2 3 4 5 6 SINCERE LESSONS d 17.6 miles, D 21 min d 16.2 miles, D 19 min d 6.4 miles, D 11 min d 20.4 miles, D 22 min d 12.5 miles, D 14 min d 0.3 miles, D 1 min LOGISTICS CAVEATS 1. Friday Traffic – stay in house for#5, #6 between 2-7pm 2. When in doubt, sleep in house 3. Challenges – Traffic, Weather 4. Single Biggest Determinant of success – in the car within 2minutes PROCEDURAL CAVEATS 1. Identify Culprit lesion before reaching CVL 2. Pull out standard STEMI PCI equipment 3. Prepare intravenous drips – Bivalirudin and Nitroprusside 4. Clean arterial stick 5. PCI= Guiding Catheter 6. Hydrophilic Guide wire 7. Thrombectomy 8. DES vs BMS 9. Always complete coronary information and LV 10. Closure Device

6. The STEMI Process – Lifestyle Change, Logistics, Challenges, Accidents & Traffic Violations!

7. STEMI INTERVENTIONS – IS IT WORTH ALL THIS HARD WORK & PERSONAL SACRIFICE? 565 short D2B interventions (1/2005 - present) Exactly at What Time? Off Hours vs. On Hours? Payer Information Mehta, Textbook of STEMI Interventions

8. D2B Times – SINCERE Jan 2005 – Dec 2009

9. Procedure Times – SINCERE Jan 2005 – Dec 2009

10. SINCERE- Stepwise, Logical & Standardized Approach for Performing STEMI Interventions – 10 Essential Steps  1. Meticulous EKG analysis for identifying culprit lesion  2. Clean sheath insertion, Bivalirudin as default agent  3. Quick assessment of non-culprit vessel with 6F diagnostic catheter – 2 views for LCA, 1 view for RCA  4. 6F guiding catheter, obtain optimal view of culprit lesion precisely showing the vessel cut-off and the best view to steer guide wire  5. Hydrophilic wire  6. Thrombo-aspiration, Rheolytic Thrombectomy or Clearway Catheter based upon Thrombus Grade  7. Stenting  8. Remove guide wire, ample Intracoronary Nitroprusside  9. Left Ventriculography, watch out for MR, VSD  10. Closure Device

11. Xylocaine (0 min) Time (Min) 0 5 10 15 Vascular Access (3 min) Angiography (6 min) Guiding catheter (7 min) Guidewire (9 min) Thrombo Aspiration (11 min) Stenting (13 min) Nitroprusside (14 min) LV Function (15 min) 15 Minutes… 1 2 3 4 6 7 8 9 11 12 13 14

12. Focus on the culprit lesion in the infarct-related artery STEMI lesions contain thrombus – consider thrombectomy or aspiration Establish an anticoagulation strategy: Bivalirudin has numerous benefits for this application Early upstream anti platelet strategy involving aspirin, clopidogrel and possibly Abciximab Guiding catheters of 6 French size are sufficient; venous sheaths may be avoided Hydrophilic wires appear to be very useful Administer the quick 30-sec “Plavix Test” to determine feasibility of using long-term Clopidogrel Intracoronary Nitroprusside causes profound coronary microvasculature dilation and significantly improves myocardial Blush grade For uncomplicated, successful short DTB STEMI Interventions, early hospital discharge may be feasible Achieve all 4 parameters of successful reperfusion – relief of chest pain, ST segment resolution, restoration of TIMI 3 flow, myocardial perfusion Grade 3-4 “Procedure” Improvements – Lessons from SINCERE Database (n=565)

13. The Mehta Strategy for Thrombus Management in STEMI Interventions “A selective strategy for thrombus management based upon the thrombus grade, with direct stenting recommended for low grade thrombus, thrombo- aspiration for moderate thrombus and Rheolytic thrombectomy for high grade thrombus, depending upon suitable anatomy. For unsuitable anatomy or unavailability of Rheolytic thrombectomy, a strategy of dethrombosis with i/c abciximab via the Clearway catheter is an acceptable approach”.

14. Strategy based on Thrombus-Grade for Management of the STEMI Lesion Mehta Classification – Clinics of America, Sept 2009 Aspiration thrombectomy Angio Jet 0 1 No cine angiographic characteristics of thrombus present Direct Stent+/- Pre dilatation Possible thrombus present. Angiography demonstrates reduced contrast density, haziness, irregular lesion contour or a smooth convex "meniscus" at the site of total occlusion suggestive but not diagnostic of thrombus 2 Thrombus present-small size: Definite thrombus with greatest dimensions less than or equal to ½ vessel diameter 3 Thrombus present- moderate size: Definite thrombus but with greatest linear dimension greater than ½ but less than 2 vessel diameters 4 Thrombus present- large size: As in Grade 3 but with the largest dimension greater than or equal to 2 vessel diameters 5 Total occlusion Most effective with fresh clot; organized thrombus is more resistant to debulking. Aspiration CatheterAngio Jet Grade Thrombus Definition Angiographic Examples Mehta Classification Technical Tips of Use Have different profiles, different push- ability, tractability and aspiration rates. All are 6F-compatable It is useful to stock and be familiar with the use of at least one. Flush catheter lumen well before use as it facilitates better tracking over the wire. Avoid kinking the catheter – advance slowly over the initial, softer portion of the catheter. Monitor distal tip of the guide wire as the aspiration catheter is advanced – it is not uncommon for the guide wire to advance during this maneuver Advance the aspiration catheter through the entire length of occlusive disease. Can be used from the radial route. Although LAD and some LCX may not need a TPM, I place TPM’s in all Angiojet procedures. Often, multiple passes will be required. Try to pause after every 2-3 pases to enable hemodynamics to be restored, to optimize guide wire and guiding catheter support and to evaluate the results. Often, just the first passage will restore adequate flow Resistant and stubborn thrombus will require more distal advancement that must be done more carefully. Avoid advancing in severe tortuousity and in vessels<2mm Since the Angiojet is used for large thrombus burden and high thrombus grade, consider Abciximab as adjunctive therapy

15. No Thrombus Large Thrombus Some Thrombus 3 a.m. D2B Intervention – Thrombus Calibration

16. “Process” & “Procedure” of STEMI Interventions

17. Why is it so hard to improve STEMI Processes? Is it because medicine is so primitive? Aviation - 2010 Medicine - 2010

18. EMT ED Physician Interventional Cardiologist Interventional Cardiologist allows ED to call STEMI alert ED Physician allows EMT to diagnose STEMI Improving the STEMI Process Backward Integration to Reducing D2B Times

19. Lessons from SINCERE: STEMI Transition Zones = Minefields for Medical Errors & Inefficiency EMS/Field EMS - EDED - CVL

20. D2B Efficiencies – Pre Hospital Management Pathway 1 – IT penetration with STEMI Alert Pathway 2 – Advanced Paramedics

21. Improving STEMI Processes To Reduce D2B Times

22. STEMI Interventions – Public Health Perspective Family Physician: Learn of options that exist for AMI patient; Risk Factor Modification Cardiologist: Initiate early treatment : Anti platelets; beta-blockers, anti-coagulants; narcotics; Master Triage & Transfer Interventional Cardiologist: Expert in short D2B STEMI Interventions Hospital: Provide exceptional ED, CVL and CCU services Media: Educate patients; monitor results and compliance Patient: Take care of yourself; know of treatment options; seek treatment early Politicians/Leaders: Allocate appropriate resources – the next patient may be you or your loved one!