pci for mvd: complete vs partial revascularization --partial more realistic in most patients yuejin...
TRANSCRIPT
PCI For MVD: Complete vs Partial Revascularization
--Partial More Realistic in Most Patients
Yuejin Yang MD, PhD, FACC
Cardiovascular Institute and Fu-Wai
Hopital, CAMS & PUMC
CIT 2010, Mar.31-April.3,2010, Beijing, China
Indications for Revascularization• Myocardial ischemia due to chronic severe
coronary mechanical blockages (stable AP)• Acute myocardial ischemia due to acute
coronary severe mechanical stenosis (UA or NSTEMI)• AMI due to acute coronary thrombotic total blockages (STEMI)• The evidence of myocardial ischemia or
infarction• The evidence of coronary mechanical severe
stenosis even obstructions except for non-mechanical one
Why Revascularization?• Solve the coronary mechanical blockages
– Bypass a new conduit (CABG)– Open and scarfolding the blockage lesions (PCI: stenting)
• Not for the non-mechanical obstructions• Not for thrombotic stenosis except for total
obstructions (STEMI)• Medications for the non-mechanical and less
severe coronary obstructions– Anti-spasm– Anti-platelet and anti-coagulation– Stablizing the vulnerable plaque
Why Complete Revarscularization
• CABG era– Once bypass surgery, complete
Revars.
– No routine dual-antiplatelet therapy
– No statins
– No medications for stabilizing even
preventing from progression of
the atherosclerotic plaque lesions
Why Partial Revarscularization
• DES period– Routine dual anti-platelet regimen
– Routing statins
– Medical treatment can stabilize or
prevent from lesion progression
– Borderline lesions(50%-70%):
no need for stenting without evidence
of myocardial ischemia
PCI: Complete Revascularization?• No need in some pts with MVD
– No improving long term outcomes– Just prevent myocardial ischemia and
relieve ischemic symptoms
– In pts without symptoms and ischemic evidence– In disdal coronary lesions– In senior persons– In small vessels– In 1-V CTO lesion with abundant collateral
circulations
PCI: Complete Revascularization?
• Technically impossible in some Pts– 3-V diffused disease– Diffused lesions– Small vessel CTOs– Distal severe stenosis even CTOs– Non-dominant RCA stenosis– High risk lesions (severe calcifications )– In very old, weak and high risk pts– In AMI pts with another coronary CTOs
PCI: Complete Revascularization?
• No more benefits even harmful for the pts– More stents– Much more costs – Over treatment– High risks for stent thrombosis– High risks for stent restenosis and
revascularizations– Not criterion of PCI– No faithfulness between Drs and Pts– Waste limited medical sources
PCI: Partial Revascularization• More realistic in most pts with MVD• Stenting the ischemia related vessel• Ischemic symptoms alleviated even no more• PCI only for IRA in Pts with STEMI can save life• PCI only for proximal severe stenosis can
improving quality of life and outcomes• Cost much less• Save the huge amount of medical sources and
social expenses• Affordable for more pts and families
Mr. Wang MX M 46yrs 69880209-9-18Baseline CAA: LM: OK
LAD: unremarkable Mid-LCX: CTO, but small Mid-RCA: 100% occluded (2 stents
deployed) 3 days later STEMI occurred
CAA: mid-RCA stent totally occluded
Cases 1: No need PCI for Samll LCX CTO
Baseline CAA (09-18-09)
RCA: 2 DES deployed
LM-Bif. with Severe Calcification: Technically Impossible for complete revas.
• 杜贵荣 F 80 Yrs• ACS• LM bifurcation with severe calcification
lesion• CABG strong suggested and contraindicated • IABP inserted• Kissing stenting performed• Sequential high pressure and final kissing• High pressure pre- and post-dilatation(20
atm)• IVUS checked
Baseline CAA+LVG
IABP+TFI+Balloon Predilatation
Kissing Stenting with High Pressure Deployment and Post-dilatation
Final Optimal Results
Triple-VD with Diffused Lesions:Technically Impossible for Complete
Revas.
陈立忠 M 55yrs 682710
3-VD: 均弥漫病变
LAD 弥漫病变最重 90% (做)
LCX 弥漫病变最重 90% (做)
Nondominant RCA 弥漫病变最重 90% (未做)
Baseline CAA
LAD Stenting
Dominant LCX Stenting
Cases 3 Mr. Yang XP M 62 yrs 456039
09-8-26
STEMI (IPW)×4 hrs
2001 Mid-LCX BMS×1
2004 follow-up CAA: normal
2006 Ischemic symptom-driven
Second BMS (driver) in Prox-LCX
Statin discontinued for 2 yrs due to side effects
Severe chest pain for 4 hrs
STEMI: No More Benefit of STEMI: No More Benefit of
Complete RevascularizationComplete Revascularization
Baseline CAA: LCX(IRA) definite ST occlusion
OCT Exam first, then Ballooning
was done
Conclusions • PCI of complete revascularization in multi-
vessel disease is not needed, technically impossible, no benefit and even harmful to the patients.
• On the other hand, partial revascularization of PCI is cost effective, technically feasible, and also can improve quality of life and outcomes
• Partial revascularization in PCI is more realistic in most patients with multi-vessel disease
• It can save huge amount of money even though revascularization rate might be 10% higher in partial vs complete revascularization.
Welcome Attend China Heart Conference (IHF2010) :
2nd international TR Coronary Therapeutics (TRCT)
Chaired byYue-Jin Yang MD. PhD. FACC
Co-Chaired byDr. Saito
Dr. kiemeneijiNCC, 2010/08/13-15, Beijing, China
Thank you very much !