Minimalist Immediate Mechanical Intervention A New Approach of Primary Angioplasty for Acute STsegment Elevation Myocardial Infarction

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A New Approach of Primary Angioplasty for Acute ST-Segment Elevation Myocardial Infarction Based on Minimalist Immediate Mechanical Intervention Karl Isaaz, MD, FESC, FACC Professor of Medicine Chief of the Division of Cardiology University of Saint Etienne France

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BACKGROUND Direct PCI is the treatment of choice for acute ST elevation myocardial infarction (STEMI) Superiority of stenting over balloon in angioplasty Acute vessel occlusion In-hospital recurrent ischemia Target vessel revascularization Restenosis

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BACKGROUND Primary stenting in acute STEMI: SLOW FLOW/NO REFLOW: 18%-30% (Grines et al. Stent PAMI trial. NEJM 1999) (Fry et al. ACC Current Journal Review jan/feb 2001 ) Risk of inflations with balloons proper sized to the vessel diameter reference: Rupture plaque/Dissection New antithrombotic agents (clopidogrel/anti GPIIb/IIIa)

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AIM To test the feasibility of minimalist immediate mechanical intervention (MIMI) in STEMI based on the use of the simple guidewire or very small size balloons catheters to avoid plaque large rupture or dissection combined with a maximized antithrombotic regimen to obtain immediate and sustained recanalization of totally occluded infarct related artery allowing postponed stenting in more stable conditions

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MIMI PROTOCOL YES NO TIMI 0 aspirin 250 mg NFH 70 U/Kg abcximab 0.25 mg/Kg aspirin 100mg clopidogrel 300 mg NFH 7 U/Kg/h abcximab 0,125 mg/Kg/min TIMI 3 PRIMARY STENT DEFERRED STENT guide wire ± balloons 1.5mm + 0.5mm Isaaz K et coll. Coron Artery Dis 2006; 17: 261-69

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Control Coronary Angiogram at H24 TIMI, Thrombus, Residual stenosis Thrombus absent or minimal Thrombus important Stenting or medical treatment (stenosis < 50% ) or surgery NFH 7 U/Kg/h, clopidogrel 75mg, aspirin 100mg Coronary angio at ˜ D5 Isaaz K et coll. Coron Artery Dis 2006; 17: 261-69

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POPULATION 93 successive patients among 249 pts who underwent direct PCI for acute STEMI from may 2001 to november 2002 Within 12 hours of symptoms onset Age 58 ± 11 years TIMI grade 0 flow in all patients 36 LAD, 43 RCA, 14 CX Mean delay from onset of chest pain to direct admission in cath lab: 229± 138 min Isaaz K et coll. Coron Artery Dis 2006; 17: 261-69

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RESULTS YES NO TIMI 0 n = 93 aspirin 250 mg NFH 70 U/Kg abcximab 0.25 mg/Kg TIMI 3 guide wire ± balloons 1.5mm + 0.5mm n = 77 (83%) No stenting n = 16 (17%) Primary stenting Isaaz K et coll. Coron Artery Dis 2006; 17: 261-69

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RESULTS Immediate TIMI 3 NO n = 16 Primary stenting in 16 TIMI 3 NO n = 7 YES n = 9 YES n = 77 Gidewire n = 14 (18%) 1.5 mm balloon n = 47 (61%) 2.0 mm balloon n = 14 2.5 mm balloon n = 2 Residual stenosis 80 ± 10% Total TIMI 3 rate (MIMI + primary stenting) = 92% Isaaz K et coll. Coron Artery Dis 2006; 17: 261-69

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Angiogram at H24 in 75/77 pts Reocclusion = 0 Stenting n = 35 Medical n=4 Surgery n= 18 Continuing protocol n=18 HNF 7 U/Kg/h, clopidogrel 75mg, aspirin 100mg Coronary angiogram at 6 ± 3 days Reocclusion = 0 Médical n = 2 Stenting n = 17 TIMI 3 n = 33 (94%) TIMI 3 n = 17 (100%) Isaaz K et coll. Coron Artery Dis 2006; 17: 261-69

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TIMI Frame Count Isaaz K et coll. Coron Artery Dis 2006; 17: 261-69

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ST segment resolution = 50% ST segment resolution at 1 hour in 63/75 patients (84%) with TIMI gade 3 flow after MIMI p = 0.13 p = 0.003 p = 0.048 n = 9 n = 7 n = 75 Isaaz K et coll. Coron Artery Dis 2006; 17: 261-69

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Complications Major hemorragia: 0 Minor hemorragia: - 2 femoral hematoma - 1 digestive bleeding Isaaz K et coll. Coron Artery Dis 2006; 17: 261-69

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CONCLUSIONS Minimalist immediate mechanical recanalization followed by maximized anti-thrombotic treatment is feasible in a large majority of STEMI patients without in-hospital reocclusion despite residual severe stenosis This method allows post-poned stenting in more stable conditions with low rates of TIMI flow deterioration This approach allows also to schedule alternative medical or surgical management when more suitable for the patient Need for a randomized trial Isaaz K et coll. Coron Artery Dis 2006; 17: 261-69

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	isaaz@univ-st-etienne.fr 5 Years ago.



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