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SCRIPPS CLINIC
Paul Teirstein, MD
Disclosures:
Cordis, Boston, Medtronic, Abbott:
Research Grants
Consultant
Speakers Bureau
SCRIPPS CLINIC
Ahh….the benefit of hindsight
Paul Teirstein, MD
Chief of Cardiology
Director of Interventional Cardiology
Scripps Clinic
La Jolla, California
SCRIPPS CLINIC
A Bold New Era In Cardiovascular
Disease
We need bold new lectures.
•Lectures that go deeper, ie “Ahh….the benefit of hindsight”
•Modern speakers now stress EMOTION over CONTENT
•They tell us how they feel, not what they think!
SCRIPPS CLINIC
“Ahh….the benefit of hindsight”
Ideas for future lectures:
• Phew….that data smells awfully fishy to me
• Expletive deleted! My hospital administrators are killing
me
• Blah…another one of my papers got rejected
• Wow!...that was a great case
• Yuck!.....got burned by another stent thrombosis
• Ahhh….the benefit of foresight
• Since foresight only becomes apparent in hindsight,
you cant have foresight without hindsight.
SCRIPPS CLINIC
“The farther backward you can look, the farther forward you are
likely to see."
---Winston Churchill
SCRIPPS CLINIC
“Ahh….the benefit of
hindsight”
Mistakes:
• Inadequate response to the COURAGE trial
• Our erroneous referral of too many patients to bypass
surgery
• Mistakes I have made in the cath lab
• Mistakes I have made in my career and my life
“Benefit of hindsight” is really a
chance to talk about mistakes
SCRIPPS CLINIC
COURAGE trial results
should have been more
forcefully refuted
Mistake #1
• Criminal Homicide:
Murder first degree: Premeditation, intent
Murder Second degree: intent, no premeditation
Manslaughter 1st degree (voluntary manslaughter):
• Intent, heat of passion, a reasonable person is provoked to kill
Manslaughter 2nd degree (involuntary manslaughter or negligent homicide):
• No intent, but did not act with the care and caution of a reasonable person (ie kicking brick off bridge that hits someone below)
• Reckless homicide – aware of risk but does not care, ie driving recklessly at 90 MPH
Non-Criminal homicide
• Justifiable homicide – kill to protect yourself, police officer killing in the line of duty,
• Accidental homicide: A lawful act done under a reasonable belief that no harm is possible
Homicide: n. The killing of one person by another
Harmonizing Outcomes with Revascularization and Stents in AMI
≥3400* pts with STEMI with symptom onset ≤12 hours
Emergent angiography, followed by triage to…
Primary PCICABG – Medical Rx–
UFH + GP IIb/IIIa inhibitor
(abciximab or eptifibatide)
Bivalirudin monotherapy
(± provisional GP IIb/IIIa)
Aspirin, thienopyridineR
1:1
3000 pts eligible for stent randomizationR
1:3
Bare metal stent TAXUS paclitaxel-eluting stent
*To rand 3000 stent pts
Clinical FU at 30 days, 6 months,
1 year, and then yearly through 5 years
1-Year Mortality: Cardiac and Non Cardiac
Number at risk
Bivalirudin alone
Heparin+GPIIb/IIIa
Bivalirudin alone (n=1800)
Heparin + GPIIb/IIIa (n=1802)
1800 1705 1684 1669 1520
1802 1678 1663 1646 1486
Cardiac
Non Cardiac
Mo
rtality
(%
)
0
1
2
3
4
5
Time in Months
0 1 2 3 4 5 6 7 8 9 10 11 12
3.8%
2.1%
1.3%
1.1%
HR [95%CI] =
0.57 [0.38, 0.84]
P=0.005
2.9%
1.8%
Δ = 1.1%
P=0.03
Δ = 1.7%
Mortality = 68 vs 38 pts
Excess deaths = 30
• Criminal Homicide:
Murder first degree: Premeditation, intent
Murder Second degree: intent, no premeditation
Manslaughter 1st degree (voluntary manslaughter):
• Intent, heat of passion, ie provoked to kill
Manslaughter 2nd degree (involuntary manslaughter or negligent homicide):
• No intent, but did not act with the care and caution of a reasonable person (ie kick brick off bridge)
• Reckless homicide – aware of risk but doesn‟t care,ie driving recklessly at 90 MPH
Non-Criminal homicide
• Justifiable homicide – kill to protect yourself, police officer killing in the line of duty,
• Accidental homicide: A lawful act done under a reasonable belief that no harm is possible
Homicide: n. The killing of one person by another
Hypothetical trial
The HOLIE CHUTE trial
Primary endpoint = Mortality Inexpensive trial
Expected 90% relative risk; 40 pts provides power 0.90, alpha < 0.05
DSMB halts trial early because of excess deaths in treatment group B
Group A Group B
• Criminal Homicide:
Murder first degree: Premeditation, intent
Murder Second degree: intent, no premeditation
Manslaughter 1st degree (voluntary manslaughter):
• Intent, heat of passion, ie provoked to kill
Manslaughter 2nd degree (involuntary manslaughter or negligent homicide):
• No intent, but did not act with the care and caution of a reasonable person (ie kick brick off bridge)
• Reckless homicide – aware of risk but doesn‟t care,ie driving recklessly at 90 MPH
Non-Criminal homicide
• Justifiable homicide – kill to protect yourself, police officer killing in the line of duty,
• Accidental homicide: A lawful act done under a reasonable belief that no harm is possible
Homicide: n. The killing of one person by another
COURAGE: Clinical Outcomes Utilizing
Revascularization and Aggressive
Guideline-Driven Drug Evaluation
Boden W et al. NEJM 2007;356:1503-16.
COURAGE: Inclusion Criteria
• Pts must have angiographically confirmed single or multivessel CAD (>70%) and objective evidence of ischemia
- LAD: prox or mid
- RCA: prox to PDA
- LCx: prox to PDA/PL
• Pts with classic angina, >80% lesion, without documented objective ischemia
COURAGE: Exclusion Criteria
The very highest CLINICAL risk patients were excluded Unstable angina
CCS class IV angina refractory to medical therapy
Markedly abnormal stress test
• Substantial STD or hypotensive response during Bruce I
Revascularization within the last 6 months
Unprotected LM stenosis (>50%)
Refractory heart failure or cardiogenic shock
Severe LV dysfunction (EF<30%)
19© Cordis Corporation 2007 19
52 year old
business
executive,
diabetic with
class II angina.
Adenosine
perfusion scan
shows lateral
wall ischemia.
55 yo male
with class II
angina and
anterior
ischemia
65 yo male
with two
episodes of
angina;
TMT found
ST
depression
laterally
22© Cordis Corporation 2007 22
70 yo male
with Class II
angina,
stress test:
mild anterior
ischemia
and LAD
lesions 60-
70%; By IVUS
they are both
< 4.0 mm;
23© Cordis Corporation 2007 23
77 yo male with
class 3 angina,
abnormal nuclear
study
Where high risk angiographic lesions included in COURAGE?
Local Heart team (surgeon &
interventional cardiologist) assessed
each patient in regards to:Patient’s operative risk (EuroSCORE & Parsonnet
score)
Coronary lesion complexity (newly developed
SYNTAX score)– The goal of the SYNTAX score is to provide a
tool to assist physicians in their revascularization strategies for patients with high risk lesions
Sianos et al, EuroIntervention 2005;1:219-227Valgimigli et al, Am J Cardiol 2007;99:1072-1081Serruys et al, EuroIntervention 2007;3:450-459Coronary tree segments based on the classification proposed by the AHA and modified for the ARTS study Circulation 1975; 51:31-3 & Semin Interv Cardiol 1999; 4:209-19
Leaman score, Circ 1981;63:285-299Lesions classification ACC/AHA , Circ 2001;103:3019-3041Bifurcation classification, CCI 2000;49:274-283CTO classification, J Am Coll Cardiol 1997;30:649-656
Tortuosity
Thrombus
Bifurcation
Total Occlusion
3 Vessel
Left Main
Dominance
Calcification
Number & location of
lesions
SYNTAXscore
COURAGE: Enrollment
35,539 pts screened
3071 pts eligible
32,468 Were excluded
8677 Did not meet inclusion criteria
5155 Had undocumented ischemia
3961 Did not meet protocol for vessels
6554 Were excluded for logistic reasons
18,360 Had one or more exclusions
4513 Had recent (<6 mo) revascularization
4939 Had an inadequate EF
2987 Had a contraindication to PCI
2542 Had a serious coexisting illness
1285 Had concomitant valvular dz
1203 Had class IV angina
1071 Had a failure of medical therapy
947 Had LM>50%
722 Had only restenosis (no new lesions)
528 Had complications after MI
2287 pts consented
PCI (n=1149) Medical (n=1138)
Mean follow-up 4.6 yrs
784 (26%) consent not given by MD or patient
All patients had angiography.
A lot of patients were excluded.
Were the patients who were at high risk for death
and MI excluded?
Hard Endpoints at 4.6 Years%
of
Pati
en
ts
PCI OMT PCI OMT PCI OMT
Death Spontaneous MI Revascularization
At mean
10 mos
At mean
10.8 mos
40%
P<0.001
13%
P=NS
11%
P=NS
NEJM 2007;356:1503-16; AHJ 2006;151:1173-9
Trial design
anticipated
<7%
crossovers!
SCRIPPS CLINIC
COURAGE Myths
• „COURAGE trial patients were not low risk.‟
Diabetics 34%
Heart failure 5%
Multivessel disease 70%
• No, no, no…….this is high risk
....yada, yada, yada
Peterson and Rumsfeld, NEJM 359;7, 751-752 accompanying
COURAGE QOL manuscript in NEJM
SCRIPPS CLINIC
Courage Myths
• “Although the majority of patients who received optimal medical therapy alone had improved symptoms within 3 months, 21% crossed over and received PCI.” Actually, 32.6% of OMT patients crossed over to PCI
• “Thus, a very reasonable „take-home‟ message from the COURAGE trial is to pursue optimal medical therapy initially and if this is ineffective, turn to PCI” No mention of importance of angiography to risk stratify
1/3 patients will get an extra procedure
Peterson and Rumsfeld, NEJM 359;7, 751-752 accompanying
COURAGE QOL manuscript in NEJM
SCRIPPS CLINIC
Courage Myths
Cost-Effectiveness of Percutatneous Coronary Intervention in Optimally
Treated Stable Coronary Patients
---Weintraub et al Circ Cardiovasc Qual Outcomes. 2008;1:12-30
Item PCI + medical Medical only PCI - Medical
Initial Cost $12,162 $752 $11,410
Lifetime Cost $99,820 $90,370 $9,451
But…the cost of diagnostic angiography was not included in the
medical only arm.
If the cost of the qualifying angiogram where included in the medical
arm, the cost differences would be mitigated.
Thus, the myth of COURAGE is perpetuated , i.e: “Angiography is not
required for patients with stable angina”
SCRIPPS CLINIC
How Has the COURAGE Trial Changed
My Practice?
LESSONS I HAVE LEARNED:
• You don‟t have to stent every little blockage in every
little vessel
• Fix the major, ischemia producing lesions
• Leave the small, distal, sidebranch vessels alone
unless the patient has recalcitraint angina
SCRIPPS CLINIC
Why such controversy? Are there two
different cardiologist phenotypes?
• We all agree medical therapy should be used in
most patients to reduce death and MI
Anti-thrombotics, lipid lowering, beta blockers and ACE
inhibitors
• We disagree about how to control angina. Here,
cardiologists have emotionally charged differences
of opinion:
Aggressive anti-anginal medications versus
revascularization
an oxygen molecule: O2
Revascularization Therapy For Angina:
Open the artery
Stents increase oxygen supply
The Liberated Heart
YOUR HEART VESSELS EXPAND!
42
YOUR HEART IS
IN 4 POINT
RESTRAINTS!
Beta-blockers, Nitrates,
Decrease Oxygen Demand
The Repressed Heart
Medical Therapy For Angina:
SCRIPPS CLINIC
Think About It! Are you…
• Are you a demand cutting cardiologist who wants
to repress the heart?
• Or
• Are you a supply expanding cardiologist who wants
to liberate the heart?
SCRIPPS CLINIC
THE HEART REPRESSOR?
•THE HEART LIBERATOR?
What‟s Your Phenotype?
SCRIPPS CLINIC
We should be more
aggressively against CABG,
especially when it involves
SVGs
Mistake #2
46© Cordis Corporation 2007 46
770,000810,000
850,000
920,000
980,0001,030,000
1,092,000
1,037,000
305,000 289,000296,000299,500
395,000
485,000
542,000
514,000
200,000
500,000
800,000
1,100,000
PCI Vs CABG: New Vs Old Technology
Sources: Cordis Database, Morgan Stanley
2000 2001 2002 2004 2005 2006 20072003
Angioplasty
Bypass Surgery
47
POD #1 after multi vessel revascularization:
OLD technologyPOD #1 after multi vessel revascularization:
NEW technology
SCRIPPS CLINIC
What do I dislike about bypass surgery?
• Morbidity of the procedure
• Saphenous vein grafts
• Acceleration of underlying native coronary disease
What do I like about bypass surgery?
• Left internal mammary
The Interventionalist‟s View of Bypass Surgery
52
Impact of increased sheer
stress on native disease
progression
53
Percent of Native Arteries with Progression
Progression (> 20% decrease in MLD) of atherosclerosis in native vessels was
accelerated by vein grafts and occurred in over 50% of native vessels within 2 years
of surgery
<50% stenosis <50% stenosis >50% stenosisNon Grafted Grafted Grafted
100
80
60
40
20
0
Less than 1 year
1 to 2 years
Greater than 2 years
----- Cosgrove et al. Cleveland Clinic; J Thorac and Cardiovasc Surg 82:520-530, 1981
8%
35%
0%
10%
20%
30%
40%
IMA SVG
Effect of Coronary Artery Bypass Grafting on Native
Coronary Artery Stenosis----Hamada, Y. et al. Journal of Cardiovascular Surgery 2001; 42: 159-164
p = 0.016
35% of native coronaries bypassed with a vein graft
progressed to total occlusion by 5 month angiography
SCRIPPS CLINIC
Risk Factors for
Acceleration of Coronary Disease
• Smoking
• Hypertension
• LDL cholesterol
• Obesity
• Sedentery life style
• Bypass surgery
especially saphenous vein graft implantation
The most frequently implanted
surgical graft in the U.S. is still a
saphenous vein…
and after a few years, it‟s not a pretty
site!
SCRIPPS CLINIC
2006 Isolated CABG Data:
Society of Thoracic Surgeons STS
• 156,128 patients with isolated CABG
LIMA = 88.2%
Bilateral IMA = 4.4%
Radial artery = 7.7%
---- 2006 STS database
Bilateral IMA = 27.6%
---- SYNTAX
58
By 5 years, vein graft patency was less than 40%. It was even worse for radial
artery conduits and not much better for RIMAs!
----Khot UN et al. Cleveland Clinic, Circulation. 2004;109:2086-91.
Cumulative patency (<70% stenosis) by type of graft
A contemporary study (2002-2003), 73%
received statins, 90% received aspirin!
1,820 (81%) patients underwent 12 month angiography
By 12 months ¼ of SVG‟s are occluded; 40% of
patients had at least one occluded SVG
At 1 year ITA failure was less frequent than SVG failure 8% Vs 29%
Saphenous vein graft failure
+ Native disease acceleration
= A very difficult day for the
Interventional cardiologist!
Vein graft failure profoundly increased death, MI
and revascularization
Example: The Graft Dependent Patient
• The graft dependent patient was not graft dependent before surgery.
• He is graft dependent because of surgery
SCRIPPS CLINIC
Three Great Myths of Cardiac Surgery
• Myth # 1: “Cardiologists do not obtain informed consent
from patients prior to multivessel PCI.”
No surgical consultation obtained
Risk of restenosis not disclosed
• How many cardiac surgeons do you know who inform
patients that their saphenous vein graft only have about a
50% chance of patency within 5 years?
• How many cardiac surgeons do you know who inform
patients that their underlying native vessel disease will
accelerate due to SVG bypass, making their overall
coronary diseased burden much worse when the SVG
occludes?
AWESOME 454 5
MASS-II* 408 1
SOS 988 2
ARTS 1,205 1
ERACI-II* 450 2.5
BARI* 1,829 10
EAST 392 8
CABRI 1,054 4
GABI 359 1
ERACI* 127 3
RITA* 1,011 6.5
Total 8,258
PCI vs CABGMortality
CABG better
PCIbetter Hazard*/risk ratios
.1 1 10
Pt F-U Odds ratio(no.) (yr) 95% Cl
Holmes DR Jr., Berger PB: Complex Intervention. Textbook of Interventional Cardiology, 4th
Edition, Topol EJ, editor. 2003:201-22.
One-year Rates of Repeat Revascularization in 4
CABG vs. Stent Assisted PCI Trials
Mercado et al, J thoracic Cardiovasc Surg, 2005
12.1
7.7
3.5 3.22.2
5.9
17.8
7.6
4.3 4.8
0.6
13.7
0
5
10
15
20
MACCE D/MI/CVA Death MI CVA Repeat
Revasc
Ra
te (
%)
CABG (N=897) TAXUS (N=903)
P=0.0015*
P=0.98
P=0.11
P=0.003
Serruys, Mohr ESC 2008
P=0.37
P<0.001
*Primary Endpoint
One Year Clinical OutcomesSYNTAX
SCRIPPS CLINIC
Three Great Myths of Cardiac Surgery
• Myth # 2: Target vessel revascularization rates are much
higher following PCI compared to CABG
SCRIPPS CLINIC
Repeat Revascularization Following CABG:
Interpreting Clinical Trial Results
• Several years post CABG, both the native vessel and SVG often progress to a total occlusion or diffuse disease resulting in limited options for PCI.
• Given the high threshold for repeat bypass surgery (particularly in the presence of a patent LIMA graft), many post CABG patients are not offered repeat revascularization; not because they wouldn‟t benefit from re-intervention, but because the risks are prohibitive and the likelihood of success is low.
• Thus, much of the relative increase in repeat revascularization following PCI observed in clinical trials is because the post PCI patient, in contradistinction to the post CABG patient, remains a good candidate for further revascularization.
SCRIPPS CLINIC
What‟s missing from the PCI vs
CABG trial data discussion?
• Why does the debate seem to always focus on mortality
and repeat revascularization?
• Shouldn‟t we include morbidity endpoints?
Any above complication 53% 1%
53% of CABG patients had a morbid complication compared to only 1%
of DES patients
PREVENT 4
JAMA 2005
CABG + CABG +
73
Risk of Procedural Stroke
PCI Vs CABG = 0.6% vs 1.2%, p = 0.002
12.1
7.7
3.5 3.22.2
5.9
17.8
7.6
4.3 4.8
0.6
13.7
0
5
10
15
20
MACCE D/MI/CVA Death MI CVA Repeat
Revasc
Ra
te (
%)
CABG (N=897) TAXUS (N=903)
P=0.0015*
P=0.98
P=0.11
P=0.003
Serruys, Mohr ESC 2008
P=0.37
P<0.001
*Primary Endpoint
One Year Clinical OutcomesSYNTAX
SCRIPPS CLINIC
Three Great Myths of Cardiac Surgery
• Myth # 3: Given differences in morbidity, bypass
surgery can even be compared to PCI.
If my PCI patient has a pseudo aneurysm requiring
surgical repair of the femoral artery, it is considered a
major complication that I have to defend at M&M and QA
committee. The untoward event is a small surgical
incision in the groin.
All CABG patients have a major surgical incision in the
chest. Therefore 100% of all CABG patients, by this
definition, suffer a major complication as a result of
their care plan.
80
85
90
95
100
0 1 2 3
3 VD with Disease of the Proximal LAD Artery
Years
Su
rviv
al (%
)
Hannan EL: NEJM, 2005
CP1190491-7
94.3
92.0
89.3
Stenting
CABG
91.5
88.1
84.4
A thought experiment!
Number needed to treat = 20 pts
Start with 20 pts
3 yrs post CABG = 18 pts left
3 yrs post stenting = 17 pts left
77
78
Original Article
Drug-Eluting Stents vs. Coronary-Artery Bypass Grafting in Multivessel Coronary Disease
Edward L. Hannan, et al N Engl J Med, Volume 358(4):331-341 Jan 24, 2008
Mortality (after adjustment) 7.3% for DES Vs. 6.0% for CABG
This 1.3% absolute difference (p=0.03) yields a NNT of 77
If we need to do 77 bypasses to save one life, I believe the
mortality benefit is clinically meaningless!
This point was completely missed by the lay press
SCRIPPS CLINIC
The TVR Trade-off:
Good data – Bad interpretation
• The clinician‟s perspective
Most of my patients tell me they would rather go through 3, 4 or
even 5 PCI procedures rather than go through one bypass surgery
• Yet some are using SYNTAX data to say exactly the
opposite
12.1
7.7
3.5 3.22.2
5.9
17.8
7.6
4.3 4.8
0.6
13.7
0
5
10
15
20
MACCE D/MI/CVA Death MI CVA Repeat
Revasc
Ra
te (
%)
CABG (N=897) TAXUS (N=903)
P=0.0015*
P=0.98
P=0.11
P=0.003
Serruys, Mohr ESC 2008
P=0.37
P<0.001
*Primary Endpoint
One Year Clinical OutcomesSYNTAX
Number of CABGs needed to
prevent one re-PCI = 13
At the cost of almost 4 times as
many strokes
Number needed to prevent analysis
All-Death CVA (Stroke)
Myocardial Infarction Revascularization
Stent (N=357)
CABG (N=348)
Adverse Events to 12 Months Left Main Subset
P=0.009*P=0.88*
P=0.97* P=0.02*
4.4%
4.2%2.7%
0.3%
4,1%
4.3%6.7%
12.0%
Number of CABGs needed to
prevent one re-PCI = 19
At the cost of 9 times as many
strokes
This means 18 of every 19
CABGs were unnecessary!
Number Needed to Prevent
82
54 yo business man
with angina,
dyspnea on exertion
and ischemic
dilatation on nuclear
study
83
84
85
After long
discussion, patient
requests stents
86
87
88
89
Three stents to RCA two weeks later
90
69 yo male with class III angina, antero-
lateral ischemia on cardiolyte scan, new
decrease in EF on stress echo. Angio finds
CTO of RCA with bridging collaterals and
high grade distal LM and ostial LAD.
Patient requests stents.
Single DES “cross-
over” circumflex with
final kissing balloon
inflation.
Will stage RCA chronic
occlusion.
US
VC
.TB
D.O
cto
ber
2007.P
age 9
1of
157
Safety at 12 Months (Death/CVA/MI)Left Main Subset
ITT population
9.9
8.17.4 7.7
9.2
2.1
14.5
7.0
4.5
00
2
4
6
8
10
12
14
16
18
LM all LM only LM+1VD LM+2VD LM+3VD(n=705) (n=91) (n=138) (n=218) (n=258)
P>0.99 P=0.29 P=0.72 P=0.57 P=0.11
CABG
Pati
ents
(%
)
TAXUS® Express® Stent
Presented by Dr. Serruys; TCT 2008
The safety and effectiveness of the TAXUS® Express® Stent System have not been established in the following patient populations: lesions located in the unprotected left main coronary artery
or patients with multi-vessel disease.
US
VC
.TB
D.O
cto
ber
2007.P
age 9
2of
157
Revascularizations* at 12 MonthsLeft Main Subset
ITT population
5.9
11.8
15.3 14.8
7.76.5 6.4 6.0
3.0
7.1
0
2
4
6
8
10
12
14
16
18
LM all LM only LM+1VD LM+2VD LM+3VD(n=705) (n=91) (n=138) (n=218) (n=258)
P=0.02 P=1.0 P=0.68 P=0.08 P=0.02
CABG
*Any revascularization (PCI or CABG)
Pati
ents
(%
)
TAXUS® Express® Stent
Presented by Dr. Serruys; TCT 2008The safety and effectiveness of the TAXUS® Express® Stent System have not been established in the following patient populations: lesions located in the unprotected left main coronary artery
or patients with multi-vessel disease.
Number Needed to Prevent
LM + 3VD Patients
Number of CABGs needed to
prevent one re-PCI = 11
SCRIPPS CLINIC
Who would I send CABG Surgery?
Several restenoses, large territory at risk
Diabetics with diffuse disease, particularly if small vessels but usually these are poor targets for CABG
Total occlusions with large and important territory at risk, not amenable to PCI or failed PCI
Excessive proximal tortuosity, particularly if calcified with good distal targets
95
You Can Call Me Now…
• Bypass surgery is very hard to go through more than
once
– Your saphenous vein grafts will likely close down
– Your native vessels will likely shrivel up
– Your subsequent PCI will likely be more difficult
• But, PCI can be repeated as often as you like
– And you can always have a bypass
– Sometime in the future
– Or, maybe never
…Or You Can Call Me Later
But Remember:
96
Bypass the Bypass!
SCRIPPS CLINIC
Mistakes I have made in the
cath lab
Mistake #3
Top Ten Things Not to Say
in the Cath Lab
6) Can I get a nurse in here who knows what she's
doing.
7) I just can't understand this anatomy.
It’s really weird. Where's the LAD?
8) This room is horrible...I can’t see anything I’m
doing! Can you see anything?
9) Stop that!...your killing my patient.
10) Wow! I've never done that before... lets give it a
try!
Top Ten Things Not to Say
in the Cath Lab
1) Ugh! This is the worst case I've ever had in my
entire life!
2) You smell really nice. What are you wearing?
3) I’ve got to get out of here, lets hurry up!
4) Huh? Where’d the stent go. Can anyone find the
stent?
5) No, I have no idea what vessel that is! Our job is
to fix vessels, not name them.
The Cardiovascular
Research Foundation
Lenox Hill Heart and Vascular
Institute of New York
The Cardiovascular
Research Foundation
Lenox Hill Heart and Vascular
Institute of New York
The Cardiovascular
Research Foundation
Lenox Hill Heart and Vascular
Institute of New York
The Cardiovascular
Research Foundation
Lenox Hill Heart and Vascular
Institute of New York
The Cardiovascular
Research Foundation
Lenox Hill Heart and Vascular
Institute of New York
The Cardiovascular
Research Foundation
Lenox Hill Heart and Vascular
Institute of New York
The Cardiovascular
Research Foundation
Lenox Hill Heart and Vascular
Institute of New York
The Cardiovascular
Research Foundation
Lenox Hill Heart and Vascular
Institute of New York
The Cardiovascular
Research Foundation
Lenox Hill Heart and Vascular
Institute of New York
The Cardiovascular
Research Foundation
Lenox Hill Heart and Vascular
Institute of New York
"A smart person learns from his own mistakes,
a brilliant person learns from the mistakes of
others"
--- Bill Collins (Mike's father)
4-4701 911
Beep…Beep…Beep…Beep…Beep…Be
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1171 800 Fix A StentSCRIPPS CLINIC
“Success is going from failure to
failure with no loss of
enthusiasm”
--Winston Churchill
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Stranger Then Fiction
69 yo female, fell in bathtub and hit her head.
Went to ER, CT was obtained and something
“unusual” observed.
Due to stent procedure 8 years previously at
another hospital, patient referred to cardiology
for evaluation
Cine images of chest obtained
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Lesson
Learned:
Always do a
“wire out”
shot
136
80 yo female, no
grafts, s/p double
barrel DES with
LAD in-stent
restensosis and
angina
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Mid LAD Cypher ISR
Simple re-stent with
Taxus for Cypher
ISR
A humbling
experience
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Re-stent with TAXUS
2.5 mm followed by
non-compliant 2.5
mm balloon @ 20 atm
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Some “plaque shift”
into proximal LAD.
After “discussion”
decision to deploy
second stent
….hmmmm
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Position second
2.5 mm stent
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Deploy second
stent at 18 atm
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!!!!!!!!!!!!!!!!!!!!!!!!!!!!
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Tamponade with
stent delivery
balloon at 4 atm.
But….patient is
receiving AngioMax
Patient tolorates
inflation well, insert
IABP.
Need to wait 45 min
for AngioMax to
wear off
How to pass the
time?
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Question 30
Which one of the following statements is true regarding echocardiography with
dobutamine administration in comparison with exercise echocardiography?
End of text
(A) Sensitivity and specificity are lower
(B) Oxygen demand is greater
(C) The incidence of procedural complications is lower
(D) It provides superior assessment of myocardial viability
(E) It is less desirable for assessment of risk prior to noncardiac surgery
146
Much improved.
Lets wait another 15
minutes.
147
Re-inflate balloon
for another 15
minutes
How should we
pass the time?
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Question 31
In patients over age 60, which of the following characterizes cardiovascular risk for those
who have elevated systolic blood pressure, in comparison with those who have elevated
diastolic blood pressure?
End of text
(A) Lower
(B) Equivalent
(C) Higher
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Question 36
A 60-year-old man is admitted to the hospital for treatment of atrial fibrillation,
associated with dyspnea and orthopnea, of two weeks' duration. He has had a heart
murmur for many years. Physical examination reveals pulse rate of 108 per minute
with irregularly irregular rhythm. Vital signs are otherwise normal. Cardiac examination
reveals a grade 3/6 holosystolic murmur at the apex and an S3 followed by a short
low-frequency murmur at the apex.
Electrocardiogram reveals atrial fibrillation. Chest radiograph shows moderate cardiac
enlargement and prominent vascular markings.
Therapy with digoxin, atenolol, furosemide, and potassium chloride results in marked
improvement of the patient's symptoms and slowing of the ventricular rate to 76 beats
per minute at rest. Doppler echocardiogram reveals nearly normal left ventricular
function, severe mitral regurgitation without evidence of mitral stenosis, and left atrial
dimension of 5.5 cm. Estimated left ventricular ejection fraction is 55%.
End of text
150
Which of the following is most appropriate at this time?
(A) Start warfarin therapy, and schedule semiannual evaluations including Doppler
echocardiography
(B) Start warfarin therapy, and perform direct-current cardioversion in three to four
weeks; then schedule semiannual evaluations including Doppler echocardiography
(C) Start heparin therapy, and schedule coronary angiography and mitral valve surgery
(D) Start heparin and warfarin therapy, and order transesophageal echocardiography; if
no clot is present, perform direct-current cardioversion; then schedule semiannual
evaluations including Doppler echocardiography
(E) Start warfarin and angiotensin-converting enzyme inhibitor therapy, and schedule
semiannual evaluations including Doppler echocardiography
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After another 15
minutes of balloon
tamponade, (total
inflation time 1
hour) perforation
is a bit worse.
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Remove IABP,
exchange for
second guide
catheter.
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Deflate balloon for a
few seconds to allow
passage of second
guidewire
Then, reinflate
balloon!
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Bring Jo-stent
through proximal
double barrel
stents down LAD
right up to inflated
balloon
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Position 3.0 x 12 mm
Jo-stent across
perforation
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Deploy Jo-stent @ 16
atm
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Final result
Echo: minimal
pericardial effusion
ReoPro bolus plus
infusion
Discharge next
morning: no CPK
rise, no pericardial
effusion.
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Emergency Angiogram for a 83 y.o Man Admitted
with Episodic Angina and Hypotension
The left main
coronary artery
has a 99%
stenosis, and is
intermittently
obstructing!
Patient requests
stents
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Sudden Cardiac Arrest Due to Complete
Closure of Left Main Artery – CPR!
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Emergency Balloon Inflation in Left Main Artery
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A Little More Flow but CPR Continues
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More Balloon Inflations
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Better Flow but CPR Continues!
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Now the Flow is Increasing and Cardiac
Contraction is Improving
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More Balloon Inflations
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Position Stent in Left Main Artery
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Deploy Stent in Left Main Artery
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Final Result – Normal Flow!
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3 Months Later: Asymptomatic
1701 800 Fix A StentSCRIPPS CLINIC
“Good judgement comes
from experience . . .
and experience comes from
bad judgement”
Lillehei
SCRIPPS CLINIC
Mistakes I have made in my
career and in my life
Mistake #4
SCRIPPS CLINIC
Top 10 mistakes I have made in my career
and in my life
10) I did not invent the coronary stent
9) My first automobile was a Renault...sorry
8) I took singing lessons in medical school…pointless!
7) I recently drilled a small hole in the trunk of my
Mercedes…right into the fuel tank…it‟s a long
story…I‟ll tell you at the break
6) Sending emails when upset
5) Sending emails when intoxicated
4) Thinking I could think of 10 mistakes, when all I
could come up with is 8 mistakes
1)…Not marrying my wife about 10 years sooner
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