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1 欧洲新版 STEMI 指南与临床实践 : 面临的 3 大挑战颜红兵, MD,PhD,FACC,FESC 国家心血管病中心中国医学科学院阜外医院

2 直接 PCI 的目的 Restore flow in the culprit artery. Optimize myocardial perfusion. Preserve LV function. Diminish mechanical & electrical complications. Prevent mortality!

5 Shorten time to reperfusion Reduce access site related complications Choosing the correct stent High thrombotic burden No reflow phenomenon Reperfusion injury 面临的主要挑战 STEMI with multivessel disease STEMI with cardiogenic shock Long-term DAPT management

6 挑战 1: 血栓抽吸的价值? Title Citation Class LOE 2012 ESC Guidelines STsegment elevation myocardial infarction ESC/EACTS guidelines on myocardial revascularization 2015 ACC/AHA focused update PPCI 2015 ACC/AHA focused update PPCI 2017 ESC Guidelines STsegment elevation myocardial infarction European Heart Journal 2012 Oct;33(20): Eur Heart J Oct 1;35(37): JACC JACC European Heart Journal 2017 Routine aspiration should be considered May be considered in selected patients Routine thrombectomy not useful Selective and bailout Thrombectomy not well established Routine use of thrombus aspiration is not recommended. IIa IIb III IIb III B A A C A

7 如何识别获益的患者?

10 实践 1: 血栓抽吸的价值 The management of the moderate, large thrombus burden still challenging The thrombos apiration still an important tool but not always sufficient, and no always necessary The case by case strategy using all tools : Balloon, thrombus aspiration,stent, pharmacological approach Is the best way to come to the end of thrombus

11 挑战 2: 部分还是完全血运重建?

12 IRA Early staged strategy for NCL FFR-guided strategy ( 0.8) Single setting FFR (Compare-Acute) vs. early staged (day 2-3) (DANAMI3) 多支病变 : 如何处理? IRA Later staged strategy for NCL FFR-guided strategy ( 0.8) Non-invasive (SPECT, Stress Echo evaluation) IRA = Infarct related artery, NCL = Non culprit lesions MV PPCI Same setting PCI of NCL (MV-PCI) Selected same setting PCI TIMI<3 Critical lesions ruptured plaques Cardiogenic Shock C/I in CTO and very complex PCI The ultimate goal would be to complete the revascularization during or soon following PPCI

15 获益非梗死相关动脉 1 次性 PCI Decrease infarct size by increasing collateral flow Reduce recurrent ischaemia Improve prognosis? 危害 Increase infarct size N-IRA PCI related Reduce recurrent MI Contrast induced nephropathy Plaque stabilisation Bleeding Reduce length of stay? Increase cost with no clinical benefit HARM

16 不应当 1 次处理! It is not supported by the clinical evidence It is likely to result in unnecessary PCI It is an impractical demand under current circumstances

17 临床证据不足 Most relevant RCT s did not employ this strategy The data shows that CR does not reduce hard endpoints The external validity of the current batch of RCT s is questionable

18 可能导致不必要的 PCI Fraction of patients with non-culprit lesions with FFR>0.8: DANAMI: 97/314 (30.9%) Compare-Acute: 275/575 (47.8%) Unnecessary PCI of FFR negative lesions Reduced the benefit gained from PPCI of the culprit lesion Reduced cost effectiveness

19 中心协会需要回答的问题 Which patients? 痛 Should we actually do the N-IRA? impact How do we decide if it needs doing? 广东省胸 If so- when?

20 实践 2: 1 次还是分次处理? The current evidence does not support broad use of multivessel intervention during PPCI Multivessel interventionin STEMI reduces the need for repeat interventions, not hard endpoints such as mortality/mi RCT s assessing the benefit of multivesel intervention STEMI were highly selective and their conclusions should be implemented cautiously on the general population

21 心原性休克和院外心跳骤停者死亡率仍然高

挑战 3: 器械支持血动学价值? O Gara et al. JACC. 2013.

22 挑战 3: 器械支持血动学价值? O Gara et al. JACC Windecker et al. EHJ ACC/AHA (2013) ESC (2014)

24 Pre-Shock No Hemodynamic Support 2% 3% 7.5% No Inotrope 心原性休克的发展 Low Dose Moderate Dose Shock Needs Partial Hemodynamic Support 21% One High Dose Mortality Risk with Inotrope Dosing Profound Shock Needs Full Hemodynamic Support 42% Two High Dose Adapted from Samuels LE et al, J Card Surg Jul-Aug;14(4): % Three High Dose

25 Aortic counterpulsation 经皮循环支持模式 LA to aorta (FA) circuit RA to aorta (FA) circuit LV to aorta pumping

26 基于支持水平选择策略 Atkinson TM, et al. JACC: Cardiovasc Interv 2016; 9(9):

27 Decrease preload Decrease afterload Augment CO/CPO Full circ support in CA 经皮循环支持的目的 Provide adequate organ perfusion and O2 delivery Selection of an MCS strategy should be determined by: Level of support required Hemodynamic profile desired Availability of equipment and local expertise Ability to provide support quickly Bridge patients to Recovery Decision Durable VAD Transplant Support patients through high-risk procedures / CA

28 Failing Heart Nearly Dead Heart Happy and Alive Heart

29 MCS Failing Heart Nearly Dead Heart Happy and Alive Heart

30 2011 Guidelines for PCI 美国指南的演变 2011 Guidelines for CABG 2014 Guidelines for NSTEMI 2013 Guidelines for STEMI 2015 Focused Guidelines Update for PCI/STEMI

31 美国指南要点 In a patient with STEMI, cardiogenic shock and cardiac arrest the US documents say Nothing about this unique combination 1. For Shock: Revascularization by PPCI or CABG Class I (absolutely) Regardless of the time delay, but the sooner the better 2. For Arrest: STEMI patient resuscitated from an OHCA Class I 3. In suitable patients requires considerable clinical judgment 4. Because of public reporting, be careful of heroic efforts

32 有选择性应用 Mechanical support devices improve hemodynamics Improved hemodynamics is the way out of shock Thus far no evidence for unselected patient populations Weigh risk (complications) benefit (hemodynamics) Select device on SHOCK severity and patient. No IABP. MCS will be effective in a selective patient population We need to execute these difficult studies

33 应当全部应用 There is increasing mortality in cardiogenic shock complicating myocardial infarction There is very low use of LV support IABP and inotropes increase mortality Mechanical Hemodynamic Support in Cardiogenic Shock Should be Used in All Patients! AND SHOULD BE PLACED BEFORE PCI

34 实践 3: 器械支持血动学价值 Cardiogenic shock carries a high mortality risk and requires rapid identification and intervention Multi-disciplinary collaborative approach benefits patients and aids decision making Rapid assessment, treatment, and frequent reassessment are necessary Rapid escalation of support (when appropriate) in case of inadequate response Think about the RV when planning initial support strategy Timely acute reperfusion is the most important treatment to improve outcome of STEMI With or without cardiac arrest With or without cardiogenic shock Mortality is closely related to cardiogenic shock, cardiac arrest, and the combination Regional systems of care including direct transport to PCI centers, and efficient transfer systems are essential to optimize timely reperfusion and likely will improve outcome for these high risk patients

35 欧洲新版 STEMI 指南与临床实践

我看美国DAPT指南

我看美国DAPT指南抽吸导管的应用 : Why?When?How? 颜红兵, MD,PhD,FACC,FESC 国家心血管病中心中国医学科学院阜外医院 Why? Proximal Guiding Catheter: inexpensive less selective systemic effects 抽吸导管的应用 Intralesional ClearWay Catheter: additional costs controlled