the core strategy of the cad management yu jie zhou, md, phd, facc, fscai, fhrs beijing an zhen...
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The Core strategy of the CAD The Core strategy of the CAD ManagementManagement
Yu Jie Zhou, Yu Jie Zhou, MD, PhD, FACC, FSCAI, MD, PhD, FACC, FSCAI, FHRSFHRS
Beijing An Zhen Hospital, Capital Medical Beijing An Zhen Hospital, Capital Medical University, Beijing, China University, Beijing, China 首都医科大学附属北京安贞医院首都医科大学附属北京安贞医院
Stent WarsStent Wars
1977-87
the mid-80's
Toulouse, Jacques Puel & Ulrich Sigwart first stent into a human coronary artery.1986
Palmaz-Schatz stent was approved for use in the United States.
1994
Close up again (30%)
The DES Technology Explosion
SVG angiographic patencySVG angiographic patency
Fitzgibbon GM, et al. JACC 1996;28:616-26.
SVG PathologySVG Pathology
Worldwide PCI proceduresWorldwide PCI procedures
+2% per yr
DES=“a ticking time
bomb” ?
However…
Coronary Aneurysm Coronary Aneurysm
Stent thrombosis Stent thrombosis
Stent fractureStent fracture
Problems with DES Problems with DES
Real-world data of DESRetrospective analysis of 94,384 consecutive stent implantations
from SCAAR registry, 2006-2008
Clinical Outcomes at 2 Years
European Heart Journal. 2012 Mar;33(5):606-13.
Drug-eluting stentsthe good, the bad, and the ugly !
The risk of bleeding is increased with DESThe risk of bleeding is increased with DES
Hybrid: the best of both worlds
27
10.7
2
16.4
26.1
0
5
10
15
20
25
30
BMS DES IMA SVG SVG
Eve
nt
rate
(%
)
BARI, SIRIUS, & PREVENT IV Trials
PRE
VE
NT
IV
Gra
ft o
cclu
sion
HYBRID OR
Simultaneous vs. Staged Hybrid Simultaneous vs. Staged Hybrid ProceduresProcedures
Simultaneous: Simultaneous: • Pro: convenient and economical for patients • Con: issues with antithrombotics
– Timing and dosing of clopidogrel load?– Reverse heparin with protamine?
Staged:Staged:• Pro: not need hybrid operating room
– Surgery first avoids antithrombotic issues
• Con: When there is a tight lesion in non-LAD vessel– risk of stent thrombosis
Femoral
1988 CABG
2000PCI
2001PTCAICD
2010LVAD
2012Heart transplant
1988 CABG
2000PCI
2001PTCAICD
2010LVAD
2012Heart transplant
A patient of multifocal atherosclerosisA patient of multifocal atherosclerosis
Babunashvili. Presented at EuroPCR 2011
Can we stop this Can we stop this from the early from the early
beginning?beginning?
A Heart With 67 StentsA Heart With 67 Stents
J. Am. Coll. Cardiol. 2010;56;1605
Iron manIron man
To Stent Or Not To Stent, That To Stent Or Not To Stent, That Is In Question.Is In Question.
Real Life CardiologyReal Life CardiologyOculo-Stenotic-Reflex (Oculo-Stenotic-Reflex ( 眼球眼球 --狭窄反射)狭窄反射)
Evidence based PCI procedureEvidence based PCI procedureNovel techniques on the horizon… Novel techniques on the horizon…
Computational fluid dynamics (FFRct)Computational fluid dynamics (FFRct)
In this large contemporary US cohort, nearly all acute PCIs
were classified as appropriate. For non-acute PCIs, however,
only 50% were classified as appropriate.
JAMA. 2011 Jul 6;306(1):53-61.
Reality is alarming!Reality is alarming!
Conclusion: Among patients with stable CAD
undergoing PCI, less than half were receiving OMT before PCI and approximately two-thirds
were receiving OMT at discharge following PCI.
JAMA. 2011 May 11;305(18):1882-9. OMT: Optimal Medical Therapy
Optimal Medical Therapy is Underused in US
Medical treatment for CVD remains markedly poor worldwide
PURE (Prospective Urban Rural Epidemiological) study
The Proportion of medications taken for secondary prevention
in CVD patients is
Remarkably Low !Remarkably Low !
Lancet 2011;378:1231–43
The “dead end” road from promising scientific breakthrough to real-world
remedy
The Core of CAD Management
ACS动脉粥样硬化疾病的“冰山一角”
认清本质,方能知道危险在哪里
From dust you are and to dust you return! ——Holy Bible
From dust to dust!
Volcanic eruption, earthquake, tsunami
Oil
Blood vessel “rust”
Valcano——unstable
Lipid——AS Plaque
“Dust”学说 (生
锈 )
“Fire”学说(发
火)
“Oil”学说(原
油)
动脉粥样硬化斑块的形成和发展
内皮损伤内皮损伤
单核细胞和 T淋巴细胞趋化单核细胞和 T淋巴细胞趋化
巨噬细胞吞噬氧化 LDL巨噬细胞吞噬氧化 LDL
脂纹,脂质斑块形成脂纹,脂质斑块形成
细胞黏附分子表达增加细胞黏附分子表达增加
炎性细胞进入内皮下炎性细胞进入内皮下
泡沫细胞形成泡沫细胞形成
Rust生锈
Fire发火
Oil进油
Essence of atherothrombosisEssence of atherothrombosis
Coronary Atherosclerosis Coronary Atherosclerosis Development Development
Vulnerable Plaque “ Active Volcano”Thrombotic effectACS
Calcified Plaque“ Dormant Volcano ”Hemodynamic effectStable Angina
Clinical Presentations of Coronary Disease
AS进展期
稳定型心绞痛
斑块破裂
ACS猝死
破裂斑块修复
ACS后PCI/CABG术后
The man is as old as his arteries
Peter Libby, Circulation 2001;104;365-372
斑块形成
高血压合并促 AS因子
How to Turn Back the Clock When Your Blood Vessels Grow Old Before You Do. --------By Ron Winslow
PCI = dental procedure
医疗医疗的双向性
病情病变的变化性治疗和经验的局限性患者的满意度的可变性
夸大的介入治疗的作用!
医药费用知多少?10mg Rosuvastatin=9.28元
我国每天将花费 18.57亿元 /天
医保: 16.71亿元 /天 个人: 1.86亿元 /天
Male, 67 yoMale, 67 yoNSTE-ACS on admissionNSTE-ACS on admission
Risk factors:
Hypertension 14 yr
Prior ischemic stroke 14 yr
Heavy smoker
No DM history
Clinical History:
exertional angina 3 mo
exacerbated 10 hr
ECG: V1-V6, I, AVL ST
depression 0.1-0.25mV
TnI 9.66 ng/ml; N-BNP 2915 pg/
UCG: LV lateral, apex, anterior
dyskinesia. LVDD 60mm. EF
38%. Severe MR. moderate PH.
IMI
• Frequent onset of resting chest pain
However, at the cath lab…However, at the cath lab…
• Pts had acute LV failure: severe dyspnea, orthopnea… Pts had acute LV failure: severe dyspnea, orthopnea… • HR 120-150bpm, BP 180/100 mmHg dropped to 60/40mmHgHR 120-150bpm, BP 180/100 mmHg dropped to 60/40mmHg• Remained hemodynamically unstable despite inotropic Remained hemodynamically unstable despite inotropic
agents …agents …
• General anesthesia, mechanical ventilation & ECMOGeneral anesthesia, mechanical ventilation & ECMO• Guidewire of IABP cannot be advanced due to severe Guidewire of IABP cannot be advanced due to severe
stenosis of left femoral artery stenosis of left femoral artery
AngiogramAngiogram July 28, 2010
Coronary Findings: LMd 99%, LADo 95% , D1 90%, LCXo 99%, LCXm 80%, RCAd
diffuse lesion.
AngiogramAngiogram July 28, 2010
Coronary Findings: LMd 99%, LADo 95% , LCXo 99%, LCXm 80%, RCAd diffuse lesion.
• 6F EBU 3.5• 3 Runthrough in LAD, LCX,
D1, respectively
• 2.5mm*20mm Sprinter predilated LCX
PCI TransradialPCI Transradial
PCI TransradialPCI Transradial
• Deployed a 2.75*33mm Firebird at LCXm at 12 atmDeployed a 2.75*33mm Firebird at LCXm at 12 atm
• 2.5mm*20mm Sprinter predilated LADp
PCI TransradialPCI Transradial
PCI TransradialPCI Transradial
• Deployed a 3.0*23mm Firebird at LADp at 16 atmDeployed a 3.0*23mm Firebird at LADp at 16 atm
• 3.0*12mm NC Sprinter post dilation at 20 atm3.0*12mm NC Sprinter post dilation at 20 atm
• Stent LM-LCX • 3.5mm*18mm Firebird
• Stent LM-LAD • 3.5mm*29mm Firebird
• Two 3.5mm*15mm Sequent NC at LAD, LCX
• After final Kissing
PCI TransradialPCI Transradial
• 6F JR 3.56F JR 3.5
• Predilation with 1.5*15mm & 2.5*20mm BCPredilation with 1.5*15mm & 2.5*20mm BC
PCI TransradialPCI Transradial
• Consecutively deployed 2.5*29mm , 3.0*29mm,& 3.5*33mm Consecutively deployed 2.5*29mm , 3.0*29mm,& 3.5*33mm
Firebird DES stentFirebird DES stent
After procedure…After procedure…
• T 37.8 oC• WBC 19.7*109/L• N% 95%• IV antibotics –-
sulperazon• IV ambroxol HCI
28/7
• SaO2 dropped to < 90
• Although with frequent sputum aspiration
• X ray (10:41, 31/7)• Atelectasis
After procedure…After procedure…
Sputum aspiration by Bronchoscopy Sputum aspiration by Bronchoscopy
• 10:50, 31/7 • 14:52, 31/7
After procedure…After procedure…
• Patient’s hemodynamic condition were stabilized 15 hr after having ECOM & PCI procedure
• Gradually reduced the volume of mechanical ventilation and ECMO
• Withdrew ECMO on 2nd Aug (5 days after procedure)
However, 6 hours later…However, 6 hours later…
• BP 55-85/40-50mmHg, HR 150-160 bpm• Dopamine increased from 7 ug/Kg/min to 17
ug/Kg/min• Administrated inotropes, vasoactive agents… • Condition got worse…
• ECMO 2ECMO 2ndnd time time
EchocardiogramEchocardiogram
DATE LV(EDD/ESD) LVEF%
28/7 Preprocedure 60/45 38 LV lateral, inferior, apex, anterior dyskinesia; Severe MR; moderate PH.
28/7 immediately after procedure
50 28
29/7 50/38 35
30/7 54 38
31/7 48*84 41 Moderate MR
1/8 50*80/42 45
Female, 57 yoFemale, 57 yoRecurrent angina for 10 daysRecurrent angina for 10 days
Risk factors:
No hypertension
No DM history
Med History:
PCI 6 months ago
LAD: 2.5*24 mm Resolute
& 3.0*36 mm Partner
AngiogramAngiogram March, 2013
Coronary Findings: LMd 80%, LADo 80% , LCX (-),RCA (-).
CASE
• Stent thrombosis?
• Intramural hematoma ?
• Neoatherosclerosis?
AngiogramAngiogram March, 2013
Coronary Findings: LMd 80%, LADo 80% , LCX (-),RCA (-).
CASE
Review previous PCI procedureReview previous PCI procedureAngiogramAngiogram Oct, 2012
Coronary Findings: LM (-), LADp 80% , LCX (-),RCA (-).
PCI Oct, 2012PCI Oct, 2012
• 6F EBU 3.5• BMW in LAD, S1
• 2.0mm*15mm Sprinter• 2.5*24 RESOLUTE
• 3.0*36 mm Partner •
• Unstable guiding catheter
Final results of 1Final results of 1stst PCI PCI
ONLY 5 mo • Intramural hematoma ?• Stent thrombosis?• Neoatherosclerosis?
PCI Mar, 2013PCI Mar, 2013
• 6F EBU 3.5• BMW in LAD, LCX
• 2.5mm*20mm Sprinter
• 4.0*23 mm XIENCE V
• 4.5*15 mm NC SPRINTER
Final results of 2Final results of 2ndnd PCI PCI
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