For the FITs | SCAI 2019: My Key Takeaways
SCAI 2019 was packed with studies related to intracoronary imaging, physiologic assessment and cardiogenic shock management after acute myocardial infarction (AMI). Here are my takeaways this year.
Starting with PRESSUREwire, a global registry that supports the routine practice of fractional flow reserve (FFR)-guided management of moderate coronary lesions. For 34.7 percent of patients with stable coronary artery disease or acute coronary syndromes, FFR data changed the initial treatment plan that was based on angiography.
It gets more interesting when you know that FFR changed the treatment plan: 19.1 percent of patients initially to be managed medically were switched to PCI and 51.6 percent of patients to be managed with PCI were switched to medical management. The findings from PRESSUREwire emphasize the importance of physiological assessment of moderate coronary lesions and that physiologic assessment of coronary lesions is often not performed frequently enough by the interventional community.
Suggested barriers are cutting back on catheterization laboratory cost, lack of knowledge of current evidence or lack of support of some hospitals to acquire new technologies that will drive better patient outcomes. The investigator as well as the late-breaking trial panel agreed that we need to perform more FFR in these cases to ensure we're delivering the right therapy for our patients.
From physiology to imaging, a subgroup analysis of the ULTIMATE trial showed that IVUS guidance was associated with lower rates of 12-month target vessel revascularization (TVR) compared with angiography guidance in patients with chronic kidney disease (CKD) requiring PCI with drug-eluting stents (DES). This is consistent with the main findings of ULTIMATE.
The study stresses again that by doing intracoronary imaging, we're improving the angiographic and clinical outcome of patient undergoing PCI compared with angiographic guidance alone. While the ULTIMATE findings are interesting and showed no worsening renal failure or progression to dialysis in CKD patients, the main question remains – why isn't the interventional community utilizing IVUS to its full potential? This might be driven by the demand to save cost and time in the catheterization laboratory.
More importantly, there might be a knowledge gap regarding interpreting intracoronary imaging, which falls back to the lack of a structured curriculum for imaging training during fellowship. It's recommended for all interventional fellows to be familiar with the basics of IVUS imaging during training, even if that requires traveling to offsite courses.
A highlight from SCAI 2019 is the presentation from the National Cardiogenic Shock Initiative (NCSI). NCSI was launched a few years back driven by the high rate of overall mortality (as high as 50 percent) in cardiogenic shock in patients with AMI. The NCSI developed standardized practices with mechanical circulatory support (MCS) and created an algorithm to treat patients presenting with AMI and cardiogenic shock. In 171 patients treated according to the NCSI protocol at multiple U.S. sites, survival was improved to 72 percent from 50 percent.
The NCSI protocol focused on early initiation of MCS using the Impella device before coronary intervention and stenting for the culprit vessel. The protocol also dictates the use of right heart catheterization (RHC) for hemodynamic assessment and monitoring for all patients with AMI and cardiogenic shock.
The RHC is imperative for monitoring the pulmonary pressures and to provide the numbers necessary to calculate what is called Cardiac Power Output (CPO) (CPO = MAPxCO/451), which is a strong predictor of mortality in cardiogenic shock.
Similarly, and to evaluate the hemometabolic status of these patients, serum lactate was mandated by the investigators. High CPO and low serum lactate are associated with best outcomes, while low CPO and high serum lactate are associated with worse outcomes.
As you're aware, insertion of MCS such as Impella requires large-bore vascular access, which is the focus of a first-in-human study presented as a late-breaker. The Early Bird study examined the safety and accuracy of the Saranas Early Bird™ bleed monitoring system for the detection of endovascular procedure-related bleeding events.
The monitoring device was studied in 60 patients who underwent various cardiac interventional procedures requiring small and large bore access, as well as arterial and venous vascular access. The primary endpoint was the level of agreement in bleeding detection between the Saranas Early Bird device and postprocedural computerized tomography. The device detected bleeding in 63 percent of patients, with the majority of these discovered outside the catheterization laboratory on the usual nursing floor.
This is a new and innovative way to monitor bleeding during and after the procedure when patients are at highest risk for bleeding. The device has great potential, but it should be utilized in patients who are at increased risk for vascular access bleeding. These include very obese and very thin patients, elderly patients, as well as patients with severe peripheral vascular disease and calcification which increase the risk of bleeding.
This article was authored by M. Chadi Alraies, MD, MPH, an interventional and CHIP fellow at Wayne State University, Detroit Medical Center, Detroit MI. Reach out to him on Twitter using @chadialraies.
Keywords: ACC Publications, Cardiology Magazine, Coronary Artery Disease, Shock, Cardiogenic, Drug-Eluting Stents, Research Personnel, Acute Coronary Syndrome, Fellowships and Scholarships, Renal Dialysis, Coronary Angiography, Myocardial Infarction, Stents, Registries, Calcinosis, Renal Insufficiency, Chronic, Peripheral Vascular Diseases, Renal Insufficiency, Endovascular Procedures, Cardiac Catheterization, Hemodynamics, Obesity, Algorithms, Curriculum, Percutaneous Coronary Intervention, Tomography, Lactates
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