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      Should Patients with Acute Myocardial Infarction Have Complete Revascularization at the Time of PCI of the Culprit Vessel?

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      , MD, MACC 1 ,
      Cardiovascular Innovations and Applications
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            Main article text

            For many years, cardiovascular clinicians have been making the argument that complete revascularization is the way to proceed in patients with any form of ischemic heart disease. I believe that cardiovascular surgeons agree with this approach and try their best to completely revascularize patients at the time of coronary artery bypass graft surgery.

            At the University of Florida, we, like many others in the world, treat an acute myocardial infarction as an emergency, and, if there is ST segment elevation, the patient is transported immediately to the cardiac catheterization laboratory from the emergency department, for recanalization of the culprit artery.

            The goal, of course, is to open up the vessel that has occluded and is responsible for the ST segment elevation, e.g. occlusion of the left anterior descending is associated with ST segment elevation in 1, AvL and many of the early precordial leads. The approach we have is that this “culprit lesion,” which generally is an occluded vessel but can be a very high grade stenosis, should undergo PCI to perfuse the unperfused or under-perfused area of myocardium sub-tending that vessel.

            Single Vessel Occlusion Plus Multivessel Stenoses

            If the culprit lesion is the only vessel responsible for myocardial ischemia, the procedure is terminated and the patient returned to the cardiac ward for continued medical care and initiation of cardiac rehabilitation.

            If, on the other hand, there are multiple high grade stenoses that may be responsible for continuing myocardial ischemia or other manifestations of ischemic heart disease, a decision has to be made at the time of culprit lesion recanalization whether or not to proceed with PCI of these other stenoses.

            Timing of Recanalization

            In general, we believe that there should be complete revascularization of the myocardium. The timing of PCI is the real question that needs to be addressed. One could make the argument that stenoses other than the culprit lesion should be evaluated with fractional flow reserve at the time of the PCI of the culprit lesion; however, this does add time to the procedure, more radiopaque contrast and more radiation to the patient.

            Decisions that need to be made at the time of PCI of the infarct-related coronary artery

            1. Should PCI of other stenoses, in addition to the culprit lesion undergo PCI at the conclusion of PCI of the culprit lesion?

            2. Should PCI of the non-culprit lesions be delayed but undergo PCI prior to hospital discharge?

            3. Should coronary bypass graft surgery early after PCI of the culprit lesion be done in stable patients? This can be accomplished prior to discharge or in close proximity after discharge. Timing is usually determined by the cardiac surgeon.

            4. Should a stable patient be observed and only undergo revascularization if the stable patient develops angina in the post-infarction state?

            Decision to Proceed with Angioplasty of Non Culprit Lesions

            The decision to proceed with multi-vessel angioplasty/stent at the time of PCI of the culprit vessel is made based on whether or not the initial procedure went quickly and efficiently and whether or not the other stenoses are complicated, i.e. bifurcating lesions, ostial stenoses of the left main coronary artery, etc., or simply high grade stenoses that are relatively uncomplicated. For example, if a culprit lesion is in the left anterior descending coronary artery and is easily and rapidly treated with PCI, and there is another high grade stenosis in the right coronary artery can be easily treated with PCI, then proceeding with treatment of the right coronary artery stenosis immediately after PCI of the culprit vessel seems reasonable. On the other hand, if there are multiple vessels involved with high grade stenoses that are complicated, and the patient is stable, preference should be given to PCI either at a later date but before discharge or coronary bypass graft surgery soon after discharge at a time to be determined by the cardiac surgeon.

            If the patient or the operators performing the recanalization procedure are exhausted by the initial culprit lesion procedure, in the cardiac catheterization laboratory, it may be in the best interest of all concerned to put off complete revascularization to a later date, but if PCI is used, it should be done before discharge.

            Support of Our Position

            The CvLPRIT trial investigators found that complete revascularization trumped incomplete revascularization, and there was no difference in major bleeding, stroke, or contrast-induced nephropathy. Kowalewski et al. performed a meta-analysis of randomized controlled trials and confirmed this approach of complete revascularization in ST segment elevation myocardial infarction patients with multivessel disease.

            Summary

            The weight of evidence seems to favor complete revascularization of patients with an acute myocardial infarction; this approach not only decreases major adverse cardiovascular events, but also decreases bleeding and contrast nephropathy. However, the timing of this complete revascularization is still controversial. At the University of Florida, the decision to proceed with or delay revascularization is resolved at the time of the initial revascularization procedure of the culprit vessel by the operators in the catheterization laboratory.

            FURTHER READING

            1. GershlickAH, KhanJN, KellyDJ, GreenwoodJP, SasikaranT, CurzenN, et al. Randomized trial of complete vs. lesion only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease: the CvLPRIT trial. J Am Coll Cardiol 2015;65:963.

            2. KowalewskiM, SchulzeV, BertiS, WaksmanR, KubicaJ, KołodziejczakM, et al. Complete revascularization in ST elevation myocardial infarction in multivessel disease: meta-analysis of randomized controlled trials. Heart 2015;101:1309.

            3. LevineGN, BatesER, BlankenshipJC, WaksmanR, KubicaJ, KołodziejczakM. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI guidelines for percutaneous coronary intervention in the 2013 ACCF/AHA guideline for the management of ST elevation myocardial infarction. J Am Coll Cardiol 2016;67:1235.

            4. ElgendyIY, WenX, MahmoudA, BavryAA. Complete versus culprit-only revascularization for patients with multi-vessel disease undergoing primary PCI; an updated meta-analysis of randomized trials. Catheter Cardiovasc Interv 2015. DOI 10;1002/ccd.26322.

            Author and article information

            Journal
            CVIA
            Cardiovascular Innovations and Applications
            CVIA
            Compuscript (Ireland )
            2009-8618
            2009-8618
            May 2016
            July 2016
            : 1
            : 3
            : 363-364
            Affiliations
            [1] 1Department of Medicine, University of Florida, Gainesville, FL 32610, USA
            Author notes
            Correspondence: C. Richard Conti, MD, MACC, Department of Medicine, University of Florida, Gainesville, FL 32610, USA, E-mail: richard.conti@ 123456medicine.ufl.edu
            Article
            cvia20160008
            10.15212/CVIA.2016.0008
            807b6371-32ca-4825-8cb2-49bc5004b52f
            Copyright © 2016 Cardiovascular Innovations and Applications

            This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 Unported License (CC BY-NC 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc/4.0/.

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            General medicine,Medicine,Geriatric medicine,Transplantation,Cardiovascular Medicine,Anesthesiology & Pain management

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