PCI in the patient with severely depressed ventricular function

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PCI in Specific Patients

Cardiogenic Shock
Left Main Coronary Artery Disease
Refractory Ventricular Arrhythmia
Severely Depressed Ventricular Function
Sole Remaining Conduit
Unprotected Left Main Patient
Adjuncts for High Risk PCI

PCI in Specific Lesion Types

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Vijayalakshmi Kunadian MBBS, MD, MRCP

Overview

Heart failure (HF) is a major public health problem. In the United States, 5 million patients have heart failure and annually more than one million are hospitalized with heart failure. In addition 50,000 patients die of heart failure in the United States. Coronary artery disease (CAD) is the most common cause of heart failure as a result of left ventricular systolic dysfunction (60-68%). There are no randomized studies to evaluate the best strategy to manage coronary artery disease in this patient population. However, there are a number of registry studies that evaluated percutaneous coronary intervention (PCI) and coronary artery bypass surgery (CABG) in patients with coronary artery disease and heart failure.

Mechanism of Functional Recovery after Revascularization

Patients with HF can have hibernating or stunned myocardium. Hibernating myocardium in chronically dysfunctional tissue related to inadequate myocardial blood flow[1]. Stunned myocardium refers to dysfunction in viable myocardium related to transient ischemia[2]. Previous studies have demonstrated that both hibernating myocardium and stunned myocardium can lead to left ventricular systolic dysfunction, remodeling and eventually development of heart failure. Chareonthaitawee et al demonstrated that 60% of ischemic LV dysfunction is related to dysfunctional but viable myocardium[3]. Stunned and hibernating myocardium could potentially be improved by revascularization by optimizing perfusion into the myocardium.

Management algorithm for patients with LV dysfunction and suspected CAD –Image adapted from Phillips et al. AHJ. 2007;153:S65-73

Role of PCI

The benefit of PCI in patients with heart failure related to stunned myocardium has been studied in observational studies. Keelan et al subdivided patients undergoing PCI in HF into 3 categories: group 1, ejection fraction (EF) ≤40%; group 2, EF 41% to 49%; and group 3, EF ≥50%. The respective mortality rates were 11.0%, 4.5%, and 1.9% (p <0.001) after 1 year. The composite end points of death/ myocardial infarction (MI) and death/ MI/ CABG occurred more frequently among patients in group 1. Thus, significant LV dysfunction was still associated with increased in-hospital and 1-year mortality in patients having contemporary PCI[4].

The GRACE (Global Registry of Acute Coronary Events) Registry demonstrated that the 6-month mortality was significantly lower in the PCI treated group compared to the medical therapy group (14% vs. 23.7%, p=<0.0001)[5]. PCI in chronic total occlusion in the setting of HF has been shown to be beneficial. Stenting can be safely performed in patients with HF with acceptable late adverse events.

A previous study demonstrated that patients with left ventricular ejection fraction (LVEF) ≤40% had better survival at 5 years if they received a stent compared with balloon angioplasty alone (76% for stents vs. 53% for balloon angioplasty; p<0.05). Stenting was found to be significant predictor of late survival in patients with an LVEF ≤50% and LVEF ≤40%. This study demonstrates improved 5-year survival for patients undergoing stenting compared with balloon angioplasty in patients with LVEF ≤40%[6].

A recent study compared PCI using drug eluting stents (DES) and CABG. The 2 years major adverse cardiac and cerebrovascular events free survival rate was 76% in DES group and 79% in the CABG cohort (p=NS)[7]. The same group demonstrated that DES reduced mortality and MACE compared to bare metal stents. MACE rate was 10% for the DES group and 41% for the BMS group (P = 0.003)[8].

Surgical Revascularization

The State University of New York study suggested that patients with HF who underwent PCI had better outcomes than patients who underwent medical therapy. Over the last decade management of patients with significant heart failure has improved significantly. Better medical management strategies using statins, angiotensin converting enzyme inhibitors and the use of implantable defibrillators and cardiac resynchronization therapy have significantly improved the outcome of patients with [[heart failure]. PCI has also seen significant advance in recent years with availability of drug eluting stents, intra-aortic balloon pump support and the use of low osmolar non-ionic contrast media which reduces the incidence of renal failure in patients with heart failure. Hence large randomized clinical studies in the modern era are required to determine the best revascularization strategy for patients with heart failure[9]. There are currently three randomized trials are underway to evaluate the effect of revascularization in patients with ischemic dysfunction (STICH trial, HEART trial and PARR-2 trial[10][11]).

The Role of Viability Testing

Viability studies could be beneficial in identifying patients who will benefit from revascularization. Viability can be assessed by single photon emission computed tomography (SPECT), positron emission tomography (PET), dobutamine stress echocardiography and cardiac magnetic resonance imaging (CMR). Among patients who demonstrated viability the 1-year mortality was 16% in patients who underwent medical therapy and 3.2% in those who underwent revascularization. There was no difference in mortality in those who did not demonstrate viability. CMR is now emerging as a gold standard for viability testing, but further studies are required to compare CMR viability to clinical outcomes.

Patient Selection for PCI

PCI and CABG should be considered as complimentary rather than competitive treatment for patients with heart failure. PCI could be considered in patients with focal stenosis, patients who have had prior CABG, with concomitant co-morbidities and advanced age. CABG should be considered in patients with diffuse disease pattern, complex lesions including chronic total occlusions and patients who require concomitant mitral valve surgery[12].

References

  1. Rahimtoola SH (1989). "The hibernating myocardium.". Am Heart J. 117 (1): 211–21. PMID 2783527. 
  2. Kim SJ, Depre C, Vatner SF (2003). "Novel mechanisms mediating stunned myocardium.". Heart Fail Rev. 8 (2): 143–53. PMID 12766493. 
  3. Chareonthaitawee P, Gersh BJ, Araoz PA, Gibbons RJ (2005). "Revascularization in severe left ventricular dysfunction: the role of viability testing.". J Am Coll Cardiol. 46 (4): 567–74. PMID 16098417. doi:10.1016/j.jacc.2005.03.072. 
  4. Keelan PC, Johnston JM, Koru-Sengul T, Detre KM, Williams DO, Slater J; et al. (2003). "Comparison of in-hospital and one-year outcomes in patients with left ventricular ejection fractions <or=40%, 41% to 49%, and >or=50% having percutaneous coronary revascularization.". Am J Cardiol. 91 (10): 1168–72. PMID 12745097. 
  5. Steg PG, Dabbous OH, Feldman LJ, Cohen-Solal A, Aumont MC, López-Sendón J; et al. (2004). "Determinants and prognostic impact of heart failure complicating acute coronary syndromes: observations from the Global Registry of Acute Coronary Events (GRACE).". Circulation. 109 (4): 494–9. PMID 14744970. doi:10.1161/01.CIR.0000109691.16944.DA. 
  6. Lipinski MJ, Martin RE, Cowley MJ, Goudreau E, Malloy WN, Vetrovec GW (2005). "Improved survival for stenting vs. balloon angioplasty for the treatment of coronary artery disease in patients with ischemic left ventricular dysfunction.". Catheter Cardiovasc Interv. 66 (4): 547–53. PMID 16216018. doi:10.1002/ccd.20455. 
  7. Gioia G, Matthai W, Gillin K, Dralle J, Benassi A, Gioia MF; et al. (2007). "Revascularization in severe left ventricular dysfunction: outcome comparison of drug-eluting stent implantation versus coronary artery by-pass grafting.". Catheter Cardiovasc Interv. 70 (1): 26–33. PMID 17585381. doi:10.1002/ccd.21072. 
  8. Gioia G, Matthai W, Benassi A, Rana H, Levite HA, Ewing LG (2006). "Improved survival with drug-eluting stent implantation in comparison with bare metal stent in patients with severe left ventricular dysfunction.". Catheter Cardiovasc Interv. 68 (3): 392–8. PMID 16892436. doi:10.1002/ccd.20833. 
  9. Hannan EL, Racz MJ, Walford G, Jones RH, Ryan TJ, Bennett E; et al. (2005). "Long-term outcomes of coronary-artery bypass grafting versus stent implantation.". N Engl J Med. 352 (21): 2174–83. PMID 15917382. doi:10.1056/NEJMoa040316. 
  10. Doenst T, Velazquez EJ, Beyersdorf F, Michler R, Menicanti L, Di Donato M; et al. (2005). "To STICH or not to STICH: we know the answer, but do we understand the question?". J Thorac Cardiovasc Surg. 129 (2): 246–9. PMID 15678031. doi:10.1016/j.jtcvs.2004.07.060. 
  11. Beanlands R, Nichol G, Ruddy TD, deKemp RA, Hendry P, Humen D; et al. (2003). "Evaluation of outcome and cost-effectiveness using an FDG PET-guided approach to management of patients with coronary disease and severe left ventricular dysfunction (PARR-2): rationale, design, and methods.". Control Clin Trials. 24 (6): 776–94. PMID 14662282. 
  12. Phillips HR, O'Connor CM, Rogers J (2007). "Revascularization for heart failure.". Am Heart J. 153 (4 Suppl): 65–73. PMID 17394905. doi:10.1016/j.ahj.2007.01.026. 

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