Sameer Mehta, MD, FACC, MBACourse Director, Lumenwww.stemiinterventions.comwww.lumenami.com

Conflict of Interest Statement

No conflict of interest or disclosure SINCERE database remains

independent and is not conflicted by any financial support

“Process” & “Procedure”of STEMI Interventions

“You cannot travel on the path until you become the path itself”

SINCERE LOGISTICS

1

23

4

5

6

SINCERE LESSONS

d 17.6 miles, D 21 min

d 16.2 miles, D 19 min

d 6.4 miles, D 11 min

d 20.4 miles, D 22 min

d 12.5 miles, D 14 min

d 0.3 miles, D 1 min

LOGISTICS CAVEATS1. Friday Traffic – stay in

house for#5, #6 between 2-7pm

2. When in doubt, sleep in house

3. Challenges – Traffic, Weather

4. Single Biggest Determinant

of success – in the car within

2minutes

PROCEDURAL CAVEATS1. Identify Culprit lesion before reaching CVL2. Pull out standard STEMI PCI equipment3. Prepare intravenous drips – Bivalirudin and Nitroprusside4. Clean arterial stick5. PCI= Guiding Catheter6. Hydrophilic Guide wire7. Thrombectomy8. DES vs BMS9. Always complete coronary information and LV10. Closure Device

The STEMI Process – Lifestyle Change, Logistics, Challenges, Accidents & Traffic Violations!

STEMI INTERVENTIONS – IS IT WORTH ALL THIS HARD WORK & PERSONAL SACRIFICE?

565 short D2B interventions (1/2005 - present)

Exactly at What Time?

Off Hours vs. On Hours?Payer Information

Mehta, Textbook of STEMI Interventions

D2B Times – SINCERE Jan 2005 – Dec 2009

Procedure Times – SINCERE Jan 2005 – Dec 2009

SINCERE- Stepwise, Logical & Standardized Approach for Performing STEMI Interventions – 10 Essential Steps

1. Meticulous EKG analysis for identifying culprit lesion 2. Clean sheath insertion, Bivalirudin as default agent 3. Quick assessment of non-culprit vessel with 6F

diagnostic catheter – 2 views for LCA, 1 view for RCA 4. 6F guiding catheter, obtain optimal view of culprit

lesion precisely showing the vessel cut-off and the best view to steer guide wire

5. Hydrophilic wire 6. Thrombo-aspiration, Rheolytic Thrombectomy or

Clearway Catheter based upon Thrombus Grade 7. Stenting 8. Remove guide wire, ample Intracoronary Nitroprusside 9. Left Ventriculography, watch out for MR, VSD 10. Closure Device

Xylocaine(0 min)

Time (Min)

0 5 10 15

Vascular Access(3 min)

Angiography(6 min)

Guiding catheter(7 min)

Guidewire(9 min)

Thrombo Aspiration(11 min)

Stenting(13 min)

Nitroprusside(14 min)

LV Function(15 min)

15 Minutes…

1 2 3 4 6 7 8 9 11 12 13 14

Focus on the culprit lesion in the infarct-related artery

STEMI lesions contain thrombus – consider thrombectomy or aspiration

Establish an anticoagulation strategy: Bivalirudin has numerous benefits for this application

Early upstream anti platelet strategy involving aspirin, clopidogrel and possibly Abciximab

Guiding catheters of 6 French size are sufficient; venous sheaths may be avoided

Hydrophilic wires appear to be very useful

Administer the quick 30-sec “Plavix Test” to determine feasibility of using long-term Clopidogrel

Intracoronary Nitroprusside causes profound coronary microvasculature dilation and significantly improves myocardial

Blush grade

For uncomplicated, successful short DTB STEMI Interventions, early hospital discharge may be feasible

Achieve all 4 parameters of successful reperfusion – relief of chest pain, ST segment resolution, restoration of TIMI 3 flow,

myocardial perfusion Grade 3-4

“Procedure” Improvements – Lessons from SINCERE Database (n=565)

The Mehta Strategy for Thrombus Management in STEMI Interventions

“A selective strategy for thrombus management based upon the thrombus grade, with direct

stenting recommended for low grade thrombus, thrombo-aspiration for moderate thrombus and

Rheolytic thrombectomy for high grade thrombus, depending upon suitable anatomy. For unsuitable anatomy or unavailability of

Rheolytic thrombectomy, a strategy of dethrombosis with i/c abciximab via the

Clearway catheter is an acceptable approach”.

Strategy based on Thrombus-Grade for Management of the STEMI Lesion

Mehta Classification – Clinics of America, Sept 2009

Aspiration thrombectomy

Angio Jet

0

1

No cine angiographic characteristics of thrombus present

Direct Stent+/- Pre dilatation

Possible thrombus present. Angiography demonstrates reduced contrast density, haziness, irregular lesion contour or a smooth convex "meniscus" at the site of total occlusion suggestive but not diagnostic of thrombus

2Thrombus present-small size: Definite thrombus with greatest dimensions less than or equal to ½ vessel diameter

3

Thrombus present- moderate size: Definite thrombus but with greatest linear dimension greater than ½ but less than 2 vessel diameters

4

Thrombus present- large size: As in Grade 3 but with the largest dimension greater than or equal to 2 vessel diameters

5 Total occlusion

•Most effective with fresh clot; organized thrombus is more resistant to debulking.

Aspiration Catheter

Angio Jet

GradeGrade Thrombus Thrombus DefinitionDefinition Angiographic ExamplesAngiographic Examples Mehta Mehta

ClassificatClassificationion

Technical Tips of UseTechnical Tips of Use

•Have different profiles, different push- ability, tractability and aspiration rates.

•All are 6F-compatableIt is useful to stock and be familiar with the use of at least one.•Flush catheter lumen well before use as it facilitates better tracking over the wire.•Avoid kinking the catheter – advance slowly over the initial, softer portion of the catheter.•Monitor distal tip of the guide wire as the aspiration catheter is advanced – it is not uncommon for the guide wire to advance during this maneuver•Advance the aspiration catheter through the entire length of occlusive disease.

•Can be used from the radial route. Although LAD and some LCX may not need a TPM, I place TPM’s in all Angiojet procedures.•Often, multiple passes will be required. Try to pause after every 2-3 pases to enable hemodynamics to be restored, to optimize guide wire and guiding catheter support and to evaluate the results.

•Often, just the first passage will restore adequate flow•Resistant and stubborn thrombus will require more distal advancement that must be done more carefully.

•Avoid advancing in severe tortuousity and in vessels<2mm•Since the Angiojet is used for large thrombus burden and high thrombus grade, consider Abciximab as adjunctive therapy

No Thrombus

Large Thrombus

Some Thrombus

3 a.m. D2B Intervention – Thrombus Calibration

“Process” & “Procedure”of STEMI Interventions

Why is it so hard to improve STEMI Processes? Is it because medicine is so primitive?

Aviation - 2010 Medicine - 2010

EMT ED Physician Interventional Cardiologist

Interventional Cardiologist allows ED to

call STEMI alert

ED Physician

allows EMT to diagnose

STEMI

Improving the STEMI Process

Backward Integration to Reducing D2B Times

Lessons from SINCERE:STEMI Transition Zones = Minefields for Medical Errors & Inefficiency

EMS/Field EMS - ED ED - CVL

D2B Efficiencies – Pre Hospital Management

Pathway 1 – IT penetration with STEMI Alert

Pathway 2 – Advanced Paramedics

Improving STEMI Processes

To Reduce D2B Times

STEMI Interventions – Public Health Perspective

Family Physician: Learn of options that exist for AMI patient; Risk Factor

Modification

Cardiologist: Initiate early treatment : Anti platelets; beta-blockers, anti-coagulants;

narcotics; Master Triage & Transfer

Interventional Cardiologist: Expert in short D2B STEMI Interventions

Hospital: Provide exceptional ED, CVL and CCU services

Media: Educate patients; monitor results and compliance

Patient: Take care of yourself; know of treatment options; seek treatment early

Politicians/Leaders: Allocate appropriate resources – the next patient may be you or your loved one!