how to deal with thrombus in acs "zap it" - laser for thrombus suneel talwar dorset heart...
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How to deal with thrombus in ACS "Zap it" - Laser for Thrombus
Suneel TalwarDorset Heart Centre
Royal Bournemouth Hospital
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Conflict of Interest
• Consultant/Advisory Board– Spectranetics
• Clinical & Research Grant Support– Boston Scientific Corporation– Cordis
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- Photoablation is the use of light to vaporize and remove tissue
Excimer Laser
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Photochemical
Photothermal
Photomechanical
Breaking molecular bonds
Producing thermal energy
Creating kinetic energy
Mechanism of Action
Three distinct mechanisms of action contribute to ExcimerLaser Photoablation
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UV light pulse hits tissue for 125 billionths of a second 50 microns penetration Billions of molecular bonds fractured per pulse
0 - 125 billionths of a second
Photochemical Mechanism: Breaking Molecular Bonds
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Absorption creates molecular vibration in tissue
Vibration of molecules heats intracellular water
Water vaporizes, rupturing cells Steam forms expanding vapor bubble
Photothermal Mechanism: Producing thermal energy
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Expansion and collapse of vapor bubble breaks down tissue and clears by-products away from tip
By-products of ablation are water, gas, and small particles (90%<10 microns = size of red blood cell)
400 millionths of a second
Photomechanical Mechanism: Creating kinetic energy
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The Excimer wavelength is very close to what is used in eye
surgery, indicative of its shallow depth of penetration and hence safety
The Wavelength StoryThe Wavelength Story
Excimer (CVX-300Ø)
InfraredUltraviolet
UltravioletUltraviolet vs vs. Infrared. Infrared
Excimer (ophthalmology)
CO2
Ho:YAG
308nm193nm 2090nm
10600nm
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Spectrophotometric Spectrophotometric Scan ofScan ofFresh ThrombusFresh Thrombus
0
10
20
30
40
50
60
70
0 400 500 600
Wavelenth (nm)
% A
bsor
ptio
n
Lee et al . Am J Card. 1983: 52; 876-877
Affinity for Photon AbsorptionAffinity for Photon Absorption
The Excimer wavelength is ideally suited for absorption by the acute thrombus
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The Antiplatelet Effects of Laser Energy
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placebo
60mj
30mj
The Laser inhibits platelet aggregationacting like a localized IIB IIIa Inhibitor
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Am J Cardiol 2004;93:694-701
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The data obtained from the participating centres was submitted to independent core laboratories for quantitative coronary analysis and statistical analysis.
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High risk patients included
• 30% of the patients had Diabetes • 24% had previous CABG • 23% had sustained a previous MI• 28% had a contraindication to thrombolysis• 13% presented to the cath lab with cardiogenic
shock.• The target vessel for revascularisation was an old
saphenous vein graft in 21% of patients.
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The greater amount of thrombus the betterthe result with the Laser
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High flow rates post laser
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The CARMEL Study-Complications
Death 6(4%)
Laser Induced Perforation 0
Laser Induced dissection 6(4%)
Acute closure 1(0.6%)
Laser induced no-flow 1(0.6%)
Stent induced no-flow 1(0.6%)
Groin bleeding complications 3 (2%)
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Study SummaryStudy Summary
Extended FAMILIFlow in Acute Myocardial Infarction Patients after Laser Intervention - Extended Pilot Study
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Extended FAMILI
Objective: To benchmark microvascular coronary blood flow in AMI patients after percutaneous intervention that includes excimer laser coronary atherectomy
Study Design: Prospective non-randomized study in up to 20 sites, and up to 80 patients.
Principal Investigators:
Jeffrey Moses, MD
Antonio Columbo, MD
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EXTENDED FAMILIRESULTS
Laser Success: Defined as TIMI 2-3 with > 20% reduction in %DS post laser.
Procedure Success: Defined as TIMI 3 flow and < 50% DS on final angiogram without in-hospital MACE.
- Laser Success: 94%- Procedure Success: 96%- 30 Day-MACE: 3%
Low MACE correlated with the high Blush Scores
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EXTENDED FAMILI
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Extended FAMILIExtended FAMILI
n=79 n=100 n=101 n=240 n=240 n=252 n=249
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Registry RCT-DeviceArm
RCT-Control PossisAngiojet
RCT-Control Guardwire Control
Ext FAMILI X-Amine AIMI EMERALD
Blush 0/1
Blush 2
Blush 3p<0.001
p<0.001
p=0.009
p<0.001
p<0.001
p<0.001
Blush Post-ProcedureBlush Post-Procedure
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Svilaas T et al. N Engl J Med 2008;358:557-567
Thrombus Aspiration during Primary PCI: TAPAS study
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Extended FAMILI: Conclusions
– Laser appears safe for thrombus ablation in Acute MI: 30 Day MACE 3%
– High Procedural Success Rate of 91%
– Extended FAMILI appears equivalent in TIMI flow rates compared to other thrombectomy studies.
– Blush scores post-procedure appear to be significantly better than the other thrombectomy studies.
.
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TAAMI: Thrombus Ablation in Acute Myocardial Infarction
• Randomised controlled study comparing a Laser-Stent strategy to a Balloon-Stent strategy
• N= 200
• 5 sites in Poland
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TAAMI: Thrombus Ablation in Acute Myocardial Infarction
• Primary Endpoint - Complete ST resolution and MBG 3 immediately post procedure
• Secondary Endpoint- MACE 30 days
- MBG
- TIMI Flow rates post Laser
- TIMI frame count
- ST reolution at 60 minutes post procedure
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Our Approach in AMI
• Turn on the Laser prior to arrival of patient in the Lab to avoid delays
• Laser Catheter: For most total occlusions start with a 0.9/1.4 catheter (both are 6F compatible)
• The laser will work over any 0.014 wire
• The vapor bubble works best in a saline medium (blood and contrast must be flushed prior to lasing)
• Activate the laser a few mm proximal to the start of the lesion – to maximize the effect of the advancing vapor bubble
– and to avoid cavitation into the plaque
• Use higher energies and rates from the start (60/40)– to create a larger vapor bubble
– and lead to better inhibition of platelet aggregation
• In order to get the effect of the advancing vapor bubble, the laser catheter must be advanced very slowly (rate of <1mm per second)
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Conclusion
• The use of the excimer laser is feasible and safe in the setting of an AMI
• Laser treatment has been shown to result in significant thrombus removal, suggesting direct laser energy absorption and thrombus vaporisation
• The potential clinical benefits of the stunned platelet phenomenon await clinical confirmation
• A prospective randomised multicentre comparing this to convention angioplasty and stenting as well as thrombectomy is necessary to confirm the observations made so far