Should we dilate the non-Should we dilate the non-infarct related arteries in infarct related arteries in patients with multi-vessel patients with multi-vessel

disease?disease?

Carma Karam, MDCarma Karam, MDCardiologistCardiologist

AIHP, ACCA, FACCAIHP, ACCA, FACCClinique Clinique Médicale du RingMédicale du Ring

Since 1980, we know that AMI is Since 1980, we know that AMI is related to coronary occlusion and related to coronary occlusion and

therefore the preferred therapy is to therefore the preferred therapy is to open the IRAopen the IRA

Prevalence of total coronary occlusion during Prevalence of total coronary occlusion during the early hours of transmural myocardial the early hours of transmural myocardial

infarction.infarction.

DeWood MA, et al N Engl J Med. 1980 Oct DeWood MA, et al N Engl J Med. 1980 Oct 16;303(16):897-902.16;303(16):897-902.

Decreased prevalence of late potentials with mechanical versus Decreased prevalence of late potentials with mechanical versus thrombolysis-induced reperfusion in acute myocardial infarctionthrombolysis-induced reperfusion in acute myocardial infarction

Karam C, JLG, PGS, et al Karam C, JLG, PGS, et alHôpitalHôpital Bichat, France Bichat, France

J Am Coll Cardiol, 1996; 27:1343-1348J Am Coll Cardiol, 1996; 27:1343-1348

Many authors have shown that Many authors have shown that reperfusion obtained by angioplasty reperfusion obtained by angioplasty is superior to reperfusion obtained is superior to reperfusion obtained

with thrombolyticswith thrombolytics

Should we dilate the non-Should we dilate the non-infarct related arteries in infarct related arteries in

patients with MVD?patients with MVD?

Di Mario et al. assigned 69 STEMI patients with Di Mario et al. assigned 69 STEMI patients with multivessel disease to unbalanced multivessel disease to unbalanced

randomization with culprit lesion treatment only randomization with culprit lesion treatment only (n = 17) versus complete multivessel (n = 17) versus complete multivessel intervention (n = 52). The multivessel intervention (n = 52). The multivessel

intervention group required longer procedures intervention group required longer procedures and larger amounts of contrast, but only had a and larger amounts of contrast, but only had a trend for lower revascularization requirements trend for lower revascularization requirements

at 12 months.at 12 months.

Di Mario C, Mara S, Flavio A, et al. (HELP-AMI) study Int J Cardiovasc Interv 2004;6:128-133

Politi et al. : 214 STEMI pts with MVD culprit vessel PCI Politi et al. : 214 STEMI pts with MVD culprit vessel PCI alone (n = 84), simultaneous treatment of nonculprit (n alone (n = 84), simultaneous treatment of nonculprit (n

= 65), or culprit only + staged revascularization (n = 65). = 65), or culprit only + staged revascularization (n = 65). In-hospital mortality, unplanned rehospitalization, and In-hospital mortality, unplanned rehospitalization, and repeat revascularization more frequent in the culprit-repeat revascularization more frequent in the culprit-

vessel-only (all p < 0.05). vessel-only (all p < 0.05).

Requirement for repeat revascularization in the culprit-Requirement for repeat revascularization in the culprit-only strategy should not be considered a major adverse only strategy should not be considered a major adverse event, but rather interpreted within a global strategy in event, but rather interpreted within a global strategy in

which closer clinical follow-up is needed. which closer clinical follow-up is needed.

The sample size of these studies was grossly The sample size of these studies was grossly underpowered to detect differences in death or underpowered to detect differences in death or

recurrent MI.recurrent MI.Politi L, Sgura F, Rossi R, et al. Heart 2009 Sep 23

Multivessel intervention during primary Multivessel intervention during primary PCIPCI

Few studiesFew studies

Small number of patients Small number of patients

Trend but no statistically significant differenceTrend but no statistically significant difference

Questionable endpointsQuestionable endpoints

Underpowered sample sizeUnderpowered sample size

Randomization bias?Randomization bias?

Possible selection biasPossible selection bias

Successful culprit vessel stenting readily accomplished Successful culprit vessel stenting readily accomplished during a smooth procedure, leading to TIMI coronary during a smooth procedure, leading to TIMI coronary

flow grade 3 and nearly complete ST-segment flow grade 3 and nearly complete ST-segment resolution. resolution.

If another easy/attractive target is identified in this If another easy/attractive target is identified in this patient, the temptation to finish the procedure achieving patient, the temptation to finish the procedure achieving

complete revascularization might be high. complete revascularization might be high.

Conversely, a complex, prolonged procedure required to Conversely, a complex, prolonged procedure required to open the culprit lesion will likely discourage the operator open the culprit lesion will likely discourage the operator

from further attempts in other vessels.from further attempts in other vessels.

Fortunately, a recent study published Fortunately, a recent study published in 2010 helps answer in 2010 helps answer

the questions concerning culprit vessel the questions concerning culprit vessel only versus multivessel intervention only versus multivessel intervention

during primary PCIduring primary PCI

Culprit Vessel Percutaneous Coronary Culprit Vessel Percutaneous Coronary Intervention Versus Multivessel and Intervention Versus Multivessel and Staged Percutaneous Coronary Staged Percutaneous Coronary Intervention for ST-Segment Elevation Intervention for ST-Segment Elevation Myocardial Infarction Patients With Myocardial Infarction Patients With Multivessel DiseaseMultivessel Disease

Edward L. Hannan, Zaza Samadashvili, Edward L. Hannan, Zaza Samadashvili, Gary Walford, David R. Holmes, Jr, Gary Walford, David R. Holmes, Jr, Alice K. Jacobs, Nicholas J.Stamato,Alice K. Jacobs, Nicholas J.Stamato,

Ferdinand J. Venditti, Samin Sharma, Ferdinand J. Venditti, Samin Sharma, Spencer B. King, IIISpencer B. King, III

JACC Cardiovasc Interv 2010;3:22-31.JACC Cardiovasc Interv 2010;3:22-31.

ObjectivesObjectives

The purpose of this study was to examine the The purpose of this study was to examine the differences in in-hospital and longer-term differences in in-hospital and longer-term

mortality for STEMI pts with MVD as a function mortality for STEMI pts with MVD as a function of whether they underwent single-vessel (culprit of whether they underwent single-vessel (culprit vessel) percutaneous coronary interventions or vessel) percutaneous coronary interventions or

multivessel PCImultivessel PCI

JACC Cardiovasc Interv 2010;3:22-31.JACC Cardiovasc Interv 2010;3:22-31.

What is the best time to intervene on nonculprit What is the best time to intervene on nonculprit vessels ?vessels ?

New York between January 2003, and June 2006New York between January 2003, and June 2006

1-Pts who underwent culprit vessel PCI only 1-Pts who underwent culprit vessel PCI only 2-Pts who underwent multivessel PCI during the index 2-Pts who underwent multivessel PCI during the index procedureprocedure3-Pts undergoing nonculprit vessel PCI during the index 3-Pts undergoing nonculprit vessel PCI during the index admissionadmission4-Pts undergoing staged PCI to the nonculprit vessel within 4-Pts undergoing staged PCI to the nonculprit vessel within 60 days of admission60 days of admission

JACC Cardiovasc Interv 2010;3:22-31.JACC Cardiovasc Interv 2010;3:22-31.

MethodsMethods

Total of 4,024 ptsTotal of 4,024 pts

3,521 pts (87.5%) culprit vessel PCI only3,521 pts (87.5%) culprit vessel PCI only

Staged PCI during the index admission in 259 Staged PCI during the index admission in 259 pts (6.43%) pts (6.43%)

538 pts staged PCI within 60 days (13.37%).538 pts staged PCI within 60 days (13.37%).

JACC Cardiovasc Interv 2010;3:22-31.JACC Cardiovasc Interv 2010;3:22-31.

ResultsResults

Pts without hemodynamic compromise :Pts without hemodynamic compromise :Culprit vessel PCI lower in-hospital mortality than Culprit vessel PCI lower in-hospital mortality than

multivessel PCI during the index procedure multivessel PCI during the index procedure (0.9% vs. 2.4%, p = 0.04). (0.9% vs. 2.4%, p = 0.04).

Culprit vessel only vs nonculprit vessel during the same Culprit vessel only vs nonculprit vessel during the same hospitalization : No difference in outcome. hospitalization : No difference in outcome.

Staged multivessel PCI within 60 days : Staged multivessel PCI within 60 days : lower 12-mth mortality than culprit vessel PCI only lower 12-mth mortality than culprit vessel PCI only

(1.3% vs. 3.3%, p = 0.04).(1.3% vs. 3.3%, p = 0.04).JACC Cardiovasc Interv 2010;3:22-JACC Cardiovasc Interv 2010;3:22-

31.31.

A strategy of culprit vessel PCI only at the time A strategy of culprit vessel PCI only at the time of STEMI is associated with the best outcome in of STEMI is associated with the best outcome in

pts with MVD.pts with MVD.

Multicenter population-based study Multicenter population-based study The only one that examines long-term The only one that examines long-term

outcomes and the use of multivessel PCI after outcomes and the use of multivessel PCI after discharge as well as during the index discharge as well as during the index

admission.admission.

ConclusionConclusionof the studyof the study

Current ACC/AHA guidelines recommend culprit vessel Current ACC/AHA guidelines recommend culprit vessel PCI only in pts undergoing primary PCI (unless there is PCI only in pts undergoing primary PCI (unless there is

hemodynamic compromise) hemodynamic compromise)

This study corroborates these findings This study corroborates these findings

Since there are no data to the contrary, culprit vessel Since there are no data to the contrary, culprit vessel PCI only should remain the preferred revascularization PCI only should remain the preferred revascularization

strategy, and if there is an indication for PCI of a strategy, and if there is an indication for PCI of a nonculprit vessel, such a procedure should be nonculprit vessel, such a procedure should be

performed in a staged fashion performed in a staged fashion

The optimal timing of such a staged procedure, The optimal timing of such a staged procedure,

however, remains unclearhowever, remains unclear

Non culprit vessels primary Non culprit vessels primary intervention may lead to:intervention may lead to:

Prolonged interventions Prolonged interventions

Non culprit vessels primary Non culprit vessels primary intervention may lead to: intervention may lead to:

Contrast overload Contrast overload

Non culprit vessels primary interventionNon culprit vessels primary intervention may lead may lead to:to:

Renal impairment Renal impairment and Heart Failureand Heart Failure

Nonculprit lesion severity may be Nonculprit lesion severity may be exaggerated as the result of circulating exaggerated as the result of circulating

catecholamine-mediated catecholamine-mediated vasoconstriction, and precise evaluation vasoconstriction, and precise evaluation of revascularization requirements may be of revascularization requirements may be

hampered. hampered.

Non culprit vessels primary interventionNon culprit vessels primary intervention may lead to:may lead to:

Jeopardizing myocardial territory that Jeopardizing myocardial territory that would be of special concern in the acute would be of special concern in the acute

phasephase

Non culprit vessels primary Non culprit vessels primary interventionintervention may lead to:may lead to:

High financial costs High financial costs

Non culprit vessels primaryNon culprit vessels primary stenting might be stenting might be associated with higher rates of associated with higher rates of periprocedural periprocedural

MIMI, and with increased rates of late , and with increased rates of late revascularizations secondary to revascularizations secondary to restenosisrestenosis..

Hypothetic favorable effects of primary non-culprit Hypothetic favorable effects of primary non-culprit vessels PCIvessels PCI

Ensuring adequate, complete, early revascularization Ensuring adequate, complete, early revascularization NOT PROVEN NOT PROVEN

Lower requirement of repeated procedures Lower requirement of repeated procedures NOT PROVENNOT PROVEN

Improvement of left ventricular function Improvement of left ventricular function NOT PROVENNOT PROVEN

Reduction of hospital stay Reduction of hospital stay NOT PROVENNOT PROVEN

Reduction in hospital costs Reduction in hospital costsNOT PROVEN NOT PROVEN

Improving long-term clinical outcomeImproving long-term clinical outcomeNOT PROVENNOT PROVEN

Conclusion: Staged procedures for Conclusion: Staged procedures for multivessel disease post culprit multivessel disease post culprit

primary PCIprimary PCI