Dr. Dev PahlajaniDr. Dev PahlajaniMD,FACC,FSCAIMD,FACC,FSCAI

Primary Percutaneous Coronary Interventions in multi

vessel disease

Chief of Interventional Cardiology- Breach Candy Hospital

and Consultant Cardiologist- Nanavati Heart Institute, Mumbai

INF MI RCA LAD CXINF MI RCA LAD CX

INF MI MVK RCA LAD CXINF MI MVK RCA LAD CX

MVK PPCI RCA LAD CXMVK PPCI RCA LAD CX

MVK RCA LAD CX INF MIMVK RCA LAD CX INF MI

ANT MI LAD OM

MER ANT MI LAD OMMER ANT MI LAD OM

MER ANT MI LAD CXMER ANT MI LAD CX

PPCI-culprit VS MV VS stagedPPCI-culprit VS MV VS staged

THREE STRATEGIES1)CULPRIT ONLY: PCI confined to culprit vessel

only2)MV-PCI: all interventions during same

procedure3)STAGED PCI:PPCI of culprit vessel during index

procedure. Non culprit PCI subsequently

THREE STRATEGIES1)CULPRIT ONLY: PCI confined to culprit vessel

only2)MV-PCI: all interventions during same

procedure3)STAGED PCI:PPCI of culprit vessel during index

procedure. Non culprit PCI subsequently

Culprit Vessel Only Versus Multivessel and Staged Percutaneous Coronary

Intervention for Multivessel Disease in Patients Presenting With ST-Segment

Elevation Myocardial Infarction

Pieter J. Vlaar, Karim D. Mahmoud, ; David R. Holmes, Gert van Valkenhoef, Hans L.

Hillege, Iwan C.C. van der Horst, et al

J Am Coll Cardiol. 2011;58(7):692-703.

2656 abstracts retrieved from electronic database

2607 abstracts excluded

49 complete articles assessed according to selection criteria

•31 studies excluded based on:•25 No STEMI•4 No stratification to at least 2 of the 3 PCI strategies•1 Comparing complete vs. incomplete revascularization•1 Comparing 2 strategies for tandem lesions in culprit vessel

18 studies were included

CULPRITCULPRIT VS VS MVMV VSVS STAGEDSTAGED PCI PCI

Flow diagram of study inclusion and exclusion. PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction.

J Am Coll Cardiol. 2011;58(7):692-703.

Culprit PCI Versus MV-PCI and Staged PCI for Culprit PCI Versus MV-PCI and Staged PCI for Long-Term MortalityLong-Term Mortality

Odds ratio, IV Random95% CI

Favours culprit PCI/Favours MV PCI

Culprits only PCI

MV PCI ODDs Ratio

Study Event Total Event Total 95% CI

Prospective studies

Di Mario,2004 0 17 1 52 0.98

Khatab, 2008 3 45 2 25 0.82

Politi, 2010 13 84 6 65 1.8

Retrospective studies

Corpus,2004 42 354 5 26 0.57

Dzeiwierz , 2010

57 707 11 70 0.47

Hannan,2010 28 503 36 503 0.76

Schaaf, 2010 66 124 22 37 0.78

Toma,2010 111 1979 27 216 0.42

Total events 356 164J Am Coll Cardiol. 2011;58(7):692-703.

Prognostic Impact of Staged Versus “One-Time” Multivessel Percutaneous Intervention in Acute Myocardial Infarction

HORIZONS-AMI Trial

Ran Kornowski, Roxana Mehran, George Dangas, Eugenia Nikolsky,

Abid Assali, Bimmer E. Claessen, et al

J Am Coll Cardiol. 2011;58(7):704-711

3602 pts with STEMI with symptom onset <= 12 hoursRandomized into UFH +/- GP II b/III a inhibitor vs. Bivalirudin monotherapy (+/- provisional GP IIb/IIIa) and to BMS vs. Taxus Stent

668 patients (18.5%) with multivessel CAD underwent PCI of the culprit and non culprit lesion

Single/ One time PCI (N= 275)

Staged PCI ( N=393)

30 days, 1 year outcomes

Therapeutic strategy

STUDY PROTOCOL-ASTUDY PROTOCOL-A

All patients undergoing MV PCI J Am Coll Cardiol. 2011;58(7):704-711

668 patients with STEMI and multi vessel PCI in HORIZONS AMI

Single/One time PCI (N=275) Staged PCI (N=393)

Excluding from both groups all pts in whom the second lesion was in a vessel with TIMI 0-2 flow

Single/One time PCI (N= 165) Staged PCI (N=77)

30d, 1 year outcomes

STUDY PROTOCOL-BSTUDY PROTOCOL-B

Patients with true elective MV PCI in the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) trial. J Am Coll Cardiol. 2011;58(7):704-711

‘True elective’ MV PCI cases

Clinical Outcomes of Patients With Clinical Outcomes of Patients With Multivessel DiseaseMultivessel Disease

Time to mortality J Am Coll Cardiol. 2011;58(7):704-711

Clinical Outcomes of Patients With Clinical Outcomes of Patients With Multivessel DiseaseMultivessel Disease

Cardiac mortality J Am Coll Cardiol. 2011;58(7):704-711

Clinical Outcomes of True Elective Clinical Outcomes of True Elective PCI-Treated PatientsPCI-Treated Patients

Time to mortality J Am Coll Cardiol. 2011;58(7):704-711

Clinical Outcomes of True Elective Clinical Outcomes of True Elective PCI-Treated PatientsPCI-Treated Patients

Cardiac mortality J Am Coll Cardiol. 2011;58(7):704-711

Multi-vessel disease in AMIMulti-vessel disease in AMI

• Multi-vessel disease occurs in 40-65% of patients with AMI

• It confers higher risk in general and higher risk after intervention

• PCI of the IRA is beneficial• The benefits of treatment of non-culprit

vessels are unknown

Kahn JK et al, JACC 1990;16:1089-96Kahn JL et al, Am J Cardiol 1990;66:1045-8Muller DW et al, Am Heart J 1991;121:1042-9

Jaski BE et al, Am Heart J 1992;124:1427-33Shihara M et al, Am J Cardiol 2002;90:932-6Keeley EC, Boura JA, Grines CL. Lancet 2003;361:967-8

• More multi-vessel procedures are being done (in

elective patients and non-STEMI ACS)

• Multi-vessel stenting in the era of DES and GP

IIb/IIIa inhibitors is delivering outcomes

comparable with CABG

The case for performing multi-vessel PCI The case for performing multi-vessel PCI during infarct angioplastyduring infarct angioplasty

• Flow in non-IRA vessels is not normal and is worse in vessels with >50% stenosis

• Slow flow in the non-IRA is associated with reduced non-IRA territory wall thickening, which improves when flow returns to normal

• Enhanced function in the non-IRA territory confers a survival advantage

• Patients often have multiple complex plaques• Coronary plaque instability can be a multi-focal process• These patients have higher event rates• Treatment of these unstable plaques may be beneficial• May be crucial in patients with cardiogenic shock• Simultaneous multi-vessel PCI may reduce vascular access and anti-

coagulant related complications and reduce costsGrines CL et al. Circ 1989;80:245-53Gibson CM et al, JACC 1999;34:974-82Santoro GM, Buonamici P. Am Heart J 1999;138:126-31Gregorini L et al, Circ 1999;99:482-90

Hochman JS et al, NEJM 1999;341:625-34Goldstein JA et al, NEJM 2000;343:915-22Asakura M et al, JACC 2001;37:1284-8Hanratty CG et al, JACC 2002;40:911-6

““Costs”Costs”

• Multi-vessel PCI is more costly to the provider and the patient

• Psychological and logistic problems • Staged PCI in the same hospital admission only

attracts a single procedural cost

The case against performing multi-vessel PCI The case against performing multi-vessel PCI during infarct angioplastyduring infarct angioplasty

• Every PCI for every lesion carries a finite risk• Non-culprit lesion severity is often exaggerated during AMI• State of vasoconstriction• Enhanced thrombotic and inflammatory state persists for some

time after an AMI• Longer more complex procedures (contrast nephropathy,

haemodynamic instability)• Additional time, more radiation exposure• Additional cost of the index procedure• Benefits not proven

Fuster V et al. Circulation 1990;82:47-59Shah PK, Forrester JS. Am J Cardiol 1991;68:16-23CStewart DJ et al. JACC 1991;18:38-43Hempel SL et al. Am J Physiol 1993;264:1448-57Ambrose JA, Weinrauch M. Arch Intern Med 1996;156:1382-94Haught WH et al. Am Heart J 1996;132:1-8

Reilly MP et al. Circulation 1997;96:3314-20Bogaty P, et al. Am Heart J 1998;136:884-93Bogaty P et al, Circ 2001;103:3062-8Hanratty CG et al, JACC 2002;40:911-6Barrett TD et al, J Pharmacol Exp Ther 2002;303:1007-13

Risk factors for contrast Risk factors for contrast nephropathynephropathy

• impairment• Congestive heart failure• Mitral regurgitation• Acute myocardial infarction• Dehydration• Gender (females>males)• Route of administration (I-A > I-V)• Diabetes? (probably dependent on co-existent renal

damage)• Elderly? (ditto)• Concurrent use of NSAIDs and other nephrotoxic

drugs• Widespread evidence of arterial disease• Hypotension• Hypoalbuminaemia

Which other lesion(s) should you treat?Patients with follow-up angiograms after infarct angioplasty

Hanratty CG et al, JACC 2002;40:911-6

n=48 Infarct angiogram Non-infarct angiogram

P

Nitrate 44 (92%) 20 (42%) <0.01

Statin 11 (23%) 40 (83%) <0.01

ACE-I 14 (29%) 45 (94%) <0.01

Infarct angiogram Non-infarct angiogram

P

Ref diam (mm) 3.1 (0.8) 3.0 (0.8) 0.3

MLD (mm) 1.53 (0.51) 1.78 (0.65) <0.001

% stenosis 49.3 (14.5) 40.4 (16.6%) <0.0001

•Vasoconstriction at time of STEMI more likely an explanation than plaque regression or haemodynamic factors•If immediate revascularisation were attempted on all lesions >50%, this would prompt unnecessary PCI in 1:5 patients

Staged Vs “One-time” Multivessel PCIStaged Vs “One-time” Multivessel PCIIn AMI: Staged PCIIn AMI: Staged PCI

Total Mortality

Cardiac Mortality

Kornowski et al JACC 2011; 58:704–11

A deferred PCI strategy of non-culprit lesions should remain the standard approach, as multivessel PCI may be associated with a greater hazard for mortality and stent thrombosis.

UFH±GPIUFH±GPIUFH±GPIUFH±GPI BivalirudinBivalirudinBivalirudinBivalirudin UFH±GPIUFH±GPIUFH±GPIUFH±GPI

1:1

1:11:1 N~6,800

Radial AccessRadial Access Femoral AccessFemoral Access

Angiography

PCI

N>6,800

PI: Marco Valgimigli

MATRIX TrialMATRIX Trial

Staged Vs “One-time” Multivessel PCIStaged Vs “One-time” Multivessel PCIIn AMI: Staged PCIIn AMI: Staged PCI

Total Mortality

Cardiac Mortality

Kornowski et al JACC 2011; 58:704–11

A deferred PCI strategy of non-culprit lesions should remain the standard approach, as multivessel PCI may be associated with a greater hazard for mortality and stent thrombosis.

Mortality: IRA Only vs. Multivessel Mortality: IRA Only vs. Multivessel vs. vs. Staged PCI for MVD in STEMIStaged PCI for MVD in STEMI

Vlaar et al JACC 2011; 58:692–703

Single Vs MV PPCI Single Vs MV PPCI JACC 2011 KornowskiJACC 2011 Kornowski

• SINGLE VESSEL: I YR MORTLITY 2.3% CARD.MORT 2.0% ST.THROMB. 2.3%• MV PPCI: 1 YR MORT. 9.2% CARD.MORT. 6.2% ST.THROMB 5.7%

Mortality: IRA Only vs. Multivessel Mortality: IRA Only vs. Multivessel vs. vs. Staged PCI for MVD in STEMIStaged PCI for MVD in STEMI

Vlaar et al JACC 2011; 58:692–703

Multivessel PCI in infarct angioplastyMultivessel PCI in infarct angioplasty

79 cases collected from 8 centres of multi-vessel PCI during infarct angioplasty 79 control cases of IRA only PCI in patients with multivessel disease (matched for age

and Killip class) Not confined to shock cases (only 28% Killip IV in both groups)

Multivessel PCI Controls P

GP IIb/IIIa 59.5% 62% NS

Stenting of IRA 70.9% 45.6% <0.001

Core Lab analysis N=58 N=63

Final TIMI 3 84.4% 79.3%

IRA Dissection 3.4% 12.7%

IRA Distal embolisation 1.7% 4.8%

IRA Side branch closure 1.7% 1.6%

Non-IRA Dissection 8.8%

Non-IRA Distal embolisation 3.5%

Non-IRA Side branch closure 1.8%

Roe MT et al, Am J Cardiol 2001;88:170-3

Multi-vessel PCI in infarct angioplastyMulti-vessel PCI in infarct angioplasty

Rescue PCI Primary PCI

Multivessel PCI (n=11)

Controls (n=18)

P Multivessel PCI (n=68

Controls (n=61)

P

Death 18.2% 16.7% NS 25% 16.4% NS

ReMI 0% 0% 8.8% 1.6% 0.07

CABG 9.1% 11.2% NS 4.4% 0% 0.10

Rpt PCI 9.1% 0% NS 8.8% 11.5% NS

Composite 27.3% 27.8% NS 35.3% 27.9% NS

Stroke 0% 5.6% NS 10.3% 0% 0.01

Roe MT et al, Am J Cardiol 2001;88:170-3

Multi-vessel PCI in infarct angioplastyMulti-vessel PCI in infarct angioplasty

S in g le vesse l d isease(n = 3 1 4 )

P C I o f IR A on ly(n = 3 5 4 )

P C I o f IR A an d n on IR Aw ith in sam e p roced u re

(n = 2 6 )

P C I o f IR A an d n on IR As tag ed w ith in in d ex h osp ita lisa tion

(n = 1 2 6 )

M u lt ivesse l P C I(n = 1 5 2 )

M u lt ivesse l d isease*(n = 5 0 6 )

A M I(n = 8 2 0 )

•Patients undergoing staged procedures at a second admission excluded•*Defined as stenosis 70% of 2 epicardial vessels or their major branches•If stent, clopidogrel 75mg od x at least 4 weeks

Corpus RA et al, Am Heart J 2004;148:493-600

Multi-vessel PCI in infarct angioplastyMulti-vessel PCI in infarct angioplasty

1VD(n=314)

MVD(n=506)

P

Age 60±13 63±13 0.001

DM 23 (7.3%) 89 (18%) <0.001

HT 121 (39%) 268 (53%) <0.001

Prior MI 24 (7.6%) 104 (20.3%) <0.001

GP IIb/IIIa 93 (30%) 183 (36%) 0.05

Corpus RA et al, Am Heart J 2004;148:493-600

Multi-vessel PCI in infarct angioplastyMulti-vessel PCI in infarct angioplasty1VD (n=314) MVD (n=506) P

30-day outcomes

ReMI 2 (0.6%) 16 (3.2%) 0.02

TVR 4 (1.3%) 37 (7.3%) <0.001

CABG 4 (1.3%) 32 (6.4%) <0.001

Mortality 9 (2.9%) 38 (7.5%) 0.005

MACE 15 (4.8%) 85 (17%) <0.001

1-yr outcomes

ReMI 5 (1.6%) 30 (5.9%) 0.003

TVR 30 (9.6%) 91 (18%) <0.001

CABG 8 (2.6%) 51 (10%) <0.001

Mortality 10 (3.2%) 59 (12%) <0.001

MACE 41 (13%) 159 (31%) <0.001

MV predictors of 1 yr mortality: Renal insufficiency, MV disease, EF≤40%, Age

Corpus RA et al, Am Heart J 2004;148:493-600

Multi-vessel PCI in infarct angioplastyMulti-vessel PCI in infarct angioplastyPatients with multivessel diseasePatients with multivessel disease

IRA only (n=354) MV PCI (n=152) PSmoker 238 (67%) 83 (55%) 0.007

GP IIb/IIIa 139 (39%) 44 (29%) 0.03

Stent 307 (87%) 148 (97%) <0.001

30-day outcomes

ReMI 2 (0.6%) 14 (9.2%) <0.001

CABG 28 (8.0%) 4 (2.6%) 0.02

MACE 52 (15%) 33 (22%) 0.053

1-yr outcomes

ReMI 10 (2.8%) 20 (13%) <0.001

TVR 53 (15%) 38 (25%) 0.007

CABG 41 (12%) 10 (6.6%) 0.08

Mortality 42 (12%) 17 (11%) 0.82

MACE 98 (28%) 61 (40%) 0.006MV analysis for1-yr MACE: MV PCI OR 1.67 (95%CI 1.10-2.54, p=0.01)

Corpus RA et al, Am Heart J 2004;148:493-600

Multi-vessel PCI in infarct angioplastyMulti-vessel PCI in infarct angioplastyMulti-vessel procedures

IRA only (n=354)

MVD Same procedure (n=26)

MVD Staged, in-hospital (n=126)

P

Hospital mortality 20 (5.6%) 5 (19%) 3 (2.4%) 0.003

30-day outcomes

ReMI 2 (0.6%) 0 (0%) 14 (11%) <0.001

TVR 28 (7.9%) 1 (3.8%) 8 (6.3%) 0.66

CABG 28 (8.0%) 1 (3.8%) 2 (2.4%) 0.07

Mortality 23 (6.5%) 5 (19%) 10 (7.9%) 0.06

MACE 52 (14.7%) 6 (23%) 27 (21%) 0.15

1-yr outcomes

ReMI 10 (2.8%) 1 (3.8%) 19 (15%) <0.001

TVR 53 (15%) 3 (12%) 35 (28%) 0.004

CABG 41 (12%) 2 (7.7%) 8 (6.3%) 0.21

Mortality 42 (12%) 5 (19%) 12 (9.5%) 0.36

MACE 98 (28%) 9 (35%) 53 (41%) 0.02

Corpus RA et al, Am Heart J 2004;148:493-600

Multi-vessel PCI in infarct angioplastyMulti-vessel PCI in infarct angioplasty

ConclusionsConclusions

Patients with MVD have worse outcomes

Perform IRA PCI only

Decisions about other vessels should be guided by

objective evidence of significant residual ischaemia

Further trials needed.

Corpus RA et al, Am Heart J 2004;148:493-600

Personal experience 2005Personal experience 2005

Staged vs non-staged procedures in multivessel PCIStaged vs non-staged procedures in multivessel PCI(predominantly non-emergency)(predominantly non-emergency)

Staged (n=135) Nonstaged (n=129) P

In-hospital MACE

3 (2.2%) 6 (4.6%) 0.28

1-yr outcome

Q MI 1 (0.7%) 5 (3.9%) 0.09

TLR 23 (17.2%) 28 (21.9%) 0.34

MACE* 35 (26.1%) 46 (35.9%) 0.08

Total LOS (days) 3.56±1.49 2.24±1.89 <0.001

* Staged procedure single independent predictor of lack of MACE at 1-yr (p=0.05)

Nikolsky E et al, Am Heart J 2002;143:1017-26

……and finallyand finally

Until then…

Do things because you should do them, not because

you can!

Or, alternatively…

Just because you’ve got them,

don’t let them cloud your clinical judgement.

And keep them to yourself!

THANK YOU!!THANK YOU!!