the core strategy of the cad management yu jie zhou, md, phd, facc, fscai, fhrs beijing an zhen...

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