PCI: devil or angel? Repeated Stent Thrombosis after
Emergency PCIYu-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 Records2013.3 1st AMI AMI(Inferior,
Posterior)1st PCI PCI(RCA)
1 week later
CAG LAD: Proximal-mid 60-85%RCA: Distal 100% Thrombosis in stent
2nd PCI
Selected PCI(LAD)+Repeated PCI(RCA)
1 hour after PCI
2nd AMI
AMI(Inferior, Posterior, extensive Anterior )
3rd PCI PTCA(LAD)
Tirofiban reduction
3rd AMI
AMI(Anterior )
Tirofiban reduction
4th AMI AMI(Extensive anterior )
11stst AMI(Inferior, Posterior) 11stst PCI
23/4/20
CAG: Distal-RCA occlusion
PCI:2.75*18mm stent in RCA
22ndnd PCI( PCI(Selected PCI)
23/4/20
CAG: 60-85% in Proximal-mid LAD
PCI: 2.75*33mm,3.0*28mm in LAD
23/4/20
CAG: occlusion in a previously implanted stent in RCA
PCI:2.5*24mm stent in RCA connected with previous stent
22ndnd PCI( PCI(Selected PCI)
22ndnd AMI(Inferior, Anterior ) 33rdrd PCI
23/4/20
CAG: Occlusion in a previously implanted stent in RCA & LAD
23/4/20
22ndnd AMI(Inferior, Anterior ) 33rdrd PCI
PTCA with LAD
Antithrombotic Therapy
1st AMI1st PCI
Regular treatment(Clopidogrel 600mg)
2nd PCI Aspirin + Clopidogrel + Tirofiban(7ml/h) + LMWH
2nd AMI Tirofiban was adjusted to 14ml/h
3rd PCI
Injection from catheter: Tirofiban 20ml*2 UK 250,000uAspirin + Clopidogrel (150mgQD)+ Tirofiban(14ml/h) + Heparin
3rd AMI Aspirin(300mgBid) + Clopidogrel (150mgQD)+ Cilostazol (100mg Bid) Tirofiban(7ml/h) + Heparin
4th AMI Ditto
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
23/4/20
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
23/4/20
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
23/4/20
23/4/20
IABPIABP
ECMOECMO VentilatorVentilatorSIMV+Pressure SurportRR 8/min PEEP 6 FiO 40% Inspiration Pressure 4 Mve
3.6L
Heart rate tracking 1 :1
4044rev 3.5L/min
DiuresisSodium nitroprusside Dopamine
Therapeutic process3rd Day IABP4th Day Pump failure, Renal Failure, Respiratory Failure5th Day ECMO, Breathing machine
Antithrombotic strategyAspirin(100mgQd) + Ticagrelor(90mgBid)+ Tirofiban(5-2ml/h) + LMWHWait for an opportunity with
revascularization10th Day CAG+PTCA(ECMO+IABP)
23/4/20
PCI Up-to-dateUp-to-date CAG: Recurrence Occlusion in a previously
implanted stent Same as second AMI
PCI Up-to-dateUp-to-date PTCA with LAD & RCA
LAD: Tirofiban 10ml RCA: Tirofiban 6ml Thrombus aspiration: PCAB 3060
23/4/20
Discussion
23/4/20
2011 ACCF/AHA/SCAI Guideline for PCI
Levine et al. Circulation 2011.
Cardiogenic Shock: Recommendations
Developed with the special contribution of the European Association for Percutaneous Cardiovascular Interventions (EAPCI) et al. Eur Heart J 2010;31:2501-2555
Treatment algorithms for acute heart failure and cardiogenic shock.
23/4/20
PROs CONs
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
23/4/20
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)
23/4/20
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"
Ticagrelor Clopidogrel
Definite stent thrombosis 1.37% 1.93% 33%
Definite or probable stent thrombosis
2.21% 2.87% 25%
23/4/20
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