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Cardioprotective Effects of Postconditioning in Patients Treated with Primary PCI Evaluated with Magnetic Resonance. Jacob T Lønborg

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slide1

Cardioprotective Effects of Postconditioning in Patients Treated with Primary PCI Evaluated with Magnetic Resonance

Jacob T Lønborg

Niels Vejlstrup, Erik Jørgensen, Steffen Helqvist, Kari Saunamäki, Peter Clemmensen, Lene Holmvang, Marek Treiman, Jan S Jensen, Henning Kelbæk, Thomas Engstrøm

Department of Cardiology

Rigshospitalet

Copenhagen

Denmark

slide2
Presenter Disclosure

The authors have no disclosures with

regard to the conduct of this study

slide3
Background

Zhao et al., 2003

slide4
Background

Zhao et al., 2003

slide5
Background

Postconditioning has been suggested to reduce myocardial damage during PPCI in patients with ST-segment elevation myocardial infarction (STEMI)

However clinical experience is limited

slide6
Occluded

Reperfusion

coronary artery

Conventional

treatment

Post-

conditioning

30

30

30

30

30

30

30

30 sec

Balloon inflations - deflations

Postconditioning

slide7
Postconditioning

STEMI - PPCI

Randomization

Conventional

treatment

Postconditioning

Balloon inflation 30 sec / reperfusion 30 sec

Balloon inflation 30 sec / reperfusion 30 sec

Balloon inflation 30 sec / reperfusion 30 sec

Balloon inflation 30 sec / reperfusion 30 sec

Continue

standard treatment

Continue

standard treatment

slide8
Major inclusion criteria
  • Patients who presented with symptoms and
  • signs of their first STEMI
  • Chest pain for less than 12 hours
  • TIMI 0-I (range 0-III) in the infarct related artery
slide9
Major exclusion criteria
  • History of a previous myocardial infarction
  • Left main stenosis
  • Spontaneous reperfusion before intervention (TIMI II-III)
  • Multivessel disease (any other stenosis > 70%)
  • Cardiogenic shock
  • Stent thrombosis
slide10
Endpoints
  • Primary:
  • Infarct size measured with CMR 3 months after the initial
  • procedure (analysis blinded)
slide11
Endpoints
  • Secondary:
  • Cardiac death after 1 and15 months
  • Clinical status after 3 months (angina, heart failure)
  • TLR during hospitalization, after 1 and 15 months
  • Re-infarction during hospitalization, after 1 and 15 months
  • LVEF by CMR
slide12
Flow Chart

Screened patients

530

Eligible patients

118

Did not meet inclusion criteria

412

2 deaths

  • 123 TIMI > 1 before PCI
  • 64 no myocardial infarction
  • 44 multiple vessel disease
  • 39 linguistic problems
  • 28 duration of symptoms >12 hours
  • 28 cardiogenic shock
  • 27 did not meet inclusion criteria
  • 23 unconsciousness
  • 17 refused to participate
  • 12 stentthrombosis
  • 11 vessel unsuitable for postconditioning
  • - 24 no reason reported

30 lost to CMR

- 15 logistic problems

- 6 claustrophobia

- 3 pacemaker implantation

- 3 nephropathy

- 3 technical difficulties

86 patients for CMR

116 patients for 3-month

clinical follow-up

slide13
Baseline clinical demography

Post-

conditioning

n = 59

Conventional

Treatment

n = 59

p

Mean age (yrs)

Male gender (%)

Diabetes (%)

Hypertension (%)

Treatment for hyperlipidemia (%)

Current smoker (%)

Family history of CAD (%)

Previous myocardial infarction (%)

Previous PCI (%)

Symptom onset to balloon (min)

Time to CMR (days)

Use of GP IIb/IIIa inhibitor (%)

Use of bivalirudin (%)

61

69

7

37

46

61

37

10

7

241 ± 149

83 ± 20

83

7

62

74

7

32

41

49

31

7

8

255 ±196

84 ± 18

83

12

ns

ns

ns

ns

ns

ns

ns

ns

ns

ns

ns

ns

ns

slide14
Baseline clinical demography

Post-

conditioning

n = 59

Conventional

Treatment

n = 59

p

Mean age (yrs)

Male gender (%)

Diabetes (%)

Hypertension (%)

Treatment for hyperlipidemia (%)

Current smoker (%)

Family history of CAD (%)

Previous myocardial infarction (%)

Previous PCI (%)

Symptom onset to balloon (min)

Time to CMR (days)

Use of GP IIb/IIIa inhibitor (%)

Use of bivalirudin (%)

61

69

7

37

46

61

37

10

7

241 ± 149

83 ± 20

83

7

62

74

7

32

41

49

31

7

8

255 ±196

84 ± 18

83

12

ns

ns

ns

ns

ns

ns

ns

ns

ns

ns

ns

ns

ns

slide15
Baseline angiographic results

Post-

conditioning

n = 59

Conventional

Treatment

n = 59

p

Number of Diseased vessels (%)

1 Vessel Disease

2 Vessel Disease

3 Vessel Disease

Infarct related artery (%)

LAD

RCA

LCX / PDA / PLA/ OM / D

TIMI 0-I before procedure

Visible thrombus (%)

78

15

7

44

47

8

100

75

83

14

3

39

42

19

100

83

ns

ns

ns

ns

slide16
Baseline angiographic results

Post-

conditioning

n = 59

Conventional

Treatment

n = 59

p

Number of Diseased vessels (%)

1 Vessel Disease

2 Vessel Disease

3 Vessel Disease

Infarct related artery (%)

LAD

RCA

LCX / PDA / PLA/ OM / D

TIMI 0-I before procedure

Visible thrombus (%)

78

15

7

44

47

8

100

75

83

14

3

39

42

19

100

83

ns

ns

ns

ns

slide17
Procedural Results

Post-

conditioning

n = 59

Conventional

Treatment

n = 59

p

Type of stent (%)

None

BMS

DES

Number of stents (%)

0

1

2

3

Diameter of final balloon, mm

Length of stented segment, mm

Max deployment pressure, mmHg

Thrombectomy (%)

TIMI grade III after procedure (%)

15

6

78

15

71

12

2

3.3

19.6

17.6

10

95

17

12

69

17

68

14

2

3.3

18.1

16.2

14

88

ns

ns

ns

ns

ns

ns

ns

slide18
Procedural Results

Post-

conditioning

n = 59

Conventional

Treatment

n = 59

p

Type of stent (%)

None

BMS

DES

Number of stents (%)

0

1

2

3

Diameter of final balloon, mm

Length of stented segment, mm

Max deployment pressure, mmHg

Thrombectomy (%)

TIMI grade III after procedure (%)

15

6

78

15

71

12

2

3.3

19.6

17.6

10

95

17

12

69

17

68

14

2

3.3

18.1

16.2

14

88

ns

ns

ns

ns

ns

ns

ns

slide19
CMR – late enhancement

= Infarct mass

= LV mass

Infarct (%) = Infarct mass / LV mass

slide20
CMR – The wavefront phenomenon

Myocardium at risk

Final infarct

3 hours

96 hours

40 minutes

slide21
= Infarct

= None-infarct

AAR-ESA = Infarct / (none-infarct + Infarct)

CMR – Area At Risk

Basis

1

2

3

4

5

6

7

8

Apex

Ortiz-Pérez et al., 2007

slide22
Results - CMR

p=0.007

p=0.987

p=0.007

p=0.037

slide23
Results - CMR

Lønborg et al., 2010

slide24
Results - CMR

Infarct size - interaction test

p=0.705

AAR = Area At Risk

slide25
Clinical outcome at 3 months

Heart failure

Angina pectoris

p=0.048

p=0.362

7

slide26
Clinical outcome at 3 months

Post-

conditioning

n = 59

Conventional

Treatment

n = 59

p

Myocardial infarction, n (%)

STEMI

NSTEMI

Stent thrombosis, n (%)

Pacemaker, n (%)

PCI on target vessel, n (%)

CABG, n (%)

Death, n (%)

0 (0)

3 (5)

0 (0)

1 (2)

0 (0)

0 (0)

2 (3)

0 (0)

1 (2)

1 (2)

2 (3)

1 (2)

1 (2)

0 (0)

ns

ns

ns

ns

ns

ns

ns

slide27
Conclusion
  • Postconditioning reduces infarct size in patients with STEMI
  • Postconditioning improves functional class in patients with STEMI
  • The treatment is independently effective for all Areas At Risk
  • Postconditioning should be tested in larger clinical trials
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