Can thiệp mạch vành trì hoãn với các ca NMCT cấp đầy huyết khối

Controversies in Primary Angioplasty Delay PCI strategy in thrombus laden STEMI Does Intense Anti-coagulation Therapy for Those with Unsatisfactory Thrombectomy work? Dr Michael Liang, MBChB, FRACP, FAMS, FACC Department of Cardiology, Khoo Teck Puat Hospital Singapore Disclosure/Conflict of Interests NONE Introduction • Thrombus Laden coronary artery occurred frequently in primary angioplasty setting • Increasing “burden of thrombus” predicts the following: – – – – (1) Longer procedure time with larger amount of thrombi (2) Imminent risk of flow impairment (3) Distal embolization (4) No flow phenomenon with micro-circular obstruction and infarct expansion – (5) In treated inadequately, it may results in arrhythmia, cardiogenic shock or even death Mehta S Clinics of America Sep 2009 51 yo man, Inferior STEMI with Complete heart block and Cardiogenic shock Distal RCA – Culprit lesion Straightforward PCI with aspiration catheter 3.5x26 mm DES Procedure Time 25 mins 42 yo, Male, Inferior STEMI Grade Thrombus • Fr right radial approach • LCA – normal • RCA  • Went into complete heart block • Temporary pacing wire was inserted “Beat the clot with balloon and aspiration catheter” Eliminate Fr Aspiration Catheter Terumo 2.0x20 mm compliant balloon “Getting worse” 4Fr Angiojet • Procedure Time 1hr 58 minutes • Antiplatelet – Aspirin/Clopidogrel • days IV Integrilin (Eptifibatide) • days s/c Enoxaparin Index procedure week later with Anti-coagulation Intense Anti-coagulation Therapy for Those with Unsatisfactory Thrombectomy in STEMI • Index Procedure: achieve best flow possible with thrombectomy or balloon dilatation • IIbIIIa inhibitor infusion for at least 24 hours followed by Enoxaparin treatment dose – Sometimes both IIb/IIIa inhibitor and enoxaparin can be used together, especially in younger patient with lower bleeding risk • Dual antiplatelet – aspirin/Ticagrelor or Clopidogrel • Repeat angiography and consider PCI if appropriate – At least after 72hours of anti-coagulation 51yr M, Inferior STEMI, hours after pain onset • Grade Thrombus – Total occlusion – No angiojet available Occluded proximal RCA Unsatisfactory Result  Intense anti-coagulation • Aspirate and dilate with 3x15 mm compliant balloon • Procedure Time 1:07min • 24 hour Integrilin Infusion • days of Enoxaparin S/C bd week later 5x24 mm Liberte 46 yr old lady with lateral STEMI Grade Thrombus at ostial left circumflex artery and the first obtuse marginal branch (Filling defect >2x vessel diameter) Post-Thrombectomy Final Results Procedure time: 34 mins • After Days Enoxaparin 1mg/kg S/C BD • FFR to LAD - 0.86 • FFR to OM1 – 0.80 • Medical therapy • > 1year follow-up – Asymptomatic 65yo man with Inferior STEMI • Resolution of chest pain in lab • Grade thrombotic burden • Aspirin and clopidogrel • IV Integrilin infusion x 24hours • Enoxaparin 1mg/kg S/C days week later • Proximal RCA thrombus almost completely resolved • Residual thrombus in distal RCA with a tight distal lesion • Proceed to PCI 3x30 mm Drug-Eluting Balloon Wires both PDA/RPL 50 seconds Aspiration Catheter and 3.0 x15 mm 2x15 mm balloon to gently disrupt balloon to dilate the vessel Same 3x30 mm Drug-Eluting Balloon thrombus 30 seconds Our Experience with Intense Anti-coagulation Therapy in Grade and Thrombus Burden No 11 Male 90.9% Mean age (years), age + SD 53 + Coronary Artery Involved Left main Left anterior descending artery (9.1%) Left circumflex artery (9.1%) Right coronary artery (81.8%) Median Anti-coagulation, days (range 4-7) Anti-coagulation 24 hours of IV Integrilin infusion followed by treatment dose of Enoxaparin Significant bleeding Stenting /DEB required at relook procedure (36.3%) Sekar et al AICT 2016 Change in culprit vessel TIMI flow following intense anti-coagulation TIMI TIMI TIMI Flow Conclusion – Learning Points • The “delayed-PCI or staged strategy” following Intense anticoagulation therapy in culprit vessel with large thrombusburden is beneficial and safe in those patients with unsatisfactory thrombectomy during the index procedure • Optimum anti-coagulation regime and duration is unknown • Glycoprotein IIb/IIIa inhibitor infusion followed by Enoxaparin is recommended for at least 72 hours before restudy the coronary angiography  ... results in arrhythmia, cardiogenic shock or even death Mehta S Clinics of America Sep 2009 51 yo man, Inferior STEMI with Complete heart block and Cardiogenic shock Distal RCA – Culprit lesion... Straightforward PCI with aspiration catheter 3.5x26 mm DES Procedure Time 25 mins 42 yo, Male, Inferior STEMI Grade Thrombus • Fr right radial approach • LCA – normal • RCA  • Went into complete heart... Sometimes both IIb/IIIa inhibitor and enoxaparin can be used together, especially in younger patient with lower bleeding risk • Dual antiplatelet – aspirin/Ticagrelor or Clopidogrel • Repeat angiography