STEMI primary PCI: technical tips, including for STEMI with shock- Elias Hanna

***Please read my 3 additional comments in the comments section, regarding IVUS, regarding lack of flow despite angioplasty, and regarding heavy thrombus
0:00 Guide first or full angiogram first? Specific case of anterior MI. Guides and sizes?
4:08 Specific case of inferior MI. PCI sequence, Ikari L guide
09:47 ECG and other features of RCA vs LCx
15:54 Specific case of the CABG patient
17:41 Wiring technique
23:26 Balloon, Stenting
26:46 When to use IIb/IIIa and thrombectomy? IVUS? LVEDP and LVgram? Read also my IVUS comment under comments section.
31:47 Shock: radial access?
34:42: Shock and pre-shock: sequence of management/ intubation/PCI/LV support. Shock stage C vs D/E. IABP-SHOCK II trial
38:19 RV shock 5 management steps, beside PCI
43:54 Timing of non-culprit PCI: update from BIOVASC trial+ role of iFR/FFR vs angio+ summary approach

[@eliashanna8248]

What to do if after wiring and angioplasty, there is still no flow? This is a potential stepwise approach: 1-Ensure your wire is in the true lumen, not subintimal. Make sure the tip is moving freely (+/- the wire can move between the main vessel and the side branch anatomy). 2-If the wire feels appropriate, the most common reason for lack of flow despite PTCA is that the occlusion extends more distally than you thought. Thus, balloon more distally, and you may use a small balloon 1.5 or 2 mm to balloon distally without risking injuring a vessel segment that you may not stent. You may also just “dotter” the vessel by advancing the balloon catheter distally, without even inflating it. 3-if you still have no flow, it is possible that there is a heavy thrombus burden with distal microembolization = “no reflow”. This may be evident by the angiographic appearance of clot. Consider using IIb/IIIa, esp administered locally via dual lumen catheter. 4-Another very helpful tip at any of the above stages: consider distal contrast injection via a dual lumen catheter advanced distally (1 ml or less, via a small 2 cc syringe): - This tells you how big and how open the distal runoff is, and allows you to see that distal vessel if you have not yet. - It may show distal emboli. - It may show no-reflow, in which case the contrast stagnates but delineates the vessel. - It may also show you that your wire is in the subintima (although you should avoid doing it if you already suspect being subtintimal). ++ Do not stent if you have no flow or very poor flow. The only time one may stent with reduced distal flow is when the flow is impaired because of an obvious large dissection. I have not found IVUS to be useful in such a case. When there is no flow, you will have heavy blood stasis artifact and the whole image will be muddy.

[@RoshanLovesall]

Elias, you r really doing good work, by helping Cardiology residents throughout the world, and thereby saving thousands of lives.

[@petarbeslic991]

Exactly!!!

[@eliashanna8248]

Additional note: IVUS or OCT is particularly useful in the following instances in STEMI: **After primary PCI stenting, if hazy areas are seen surrounding the stent: is it thrombus? (treat with IIb/IIIa potentially) or dissection? (treat with additional stenting) **Before primary PCI stenting: -If MI culprit is stent thrombosis--> we need to determine the underlying mechanism: Is it stent underexpansion (treat it with high-pressure balloon or laser)? Is it a mixture of thrombus and heavy in-stent tissue growth (may require DCB or re-stenting for instent tissue growth)? -If SCAD type 2 is suspected but the angiographic features are not definite -If Culprit artery is patent (spontaneous recanalization) with residual angiographic stenosis

[@isaacjamestea9652]

As a fellow IC, hope I can meet you one day. Thank you!

[@smhmd2211]

thank you dr hanna so informative and helpful. detailed technical advices that guides us in our first steps in the cath lab

[@petarbeslic991]

Thank you very much! You are my ultimate teacher dr. Hanna! Greetings from Croatia!

[@eliashanna8248]

Thank you so much for your kind words! Greetings to Croatia

[@Docsammy]

Very informative. Thank you

[@matheuscsmed]

Thank you, Matheus Silva

[@eliashanna8248]

Here are general and additional tips on how to handle heavy thrombus burden that persists or embolizes (macro-emboli) after balloon dilatation: 1-IIb/IIIa inhibitors, consider giving them via a distal dual lumen catheter in patients with slow coronary flow 2-Penumbra thrombectomy catheter (Cat Rx) 3-If large thrombus persists, consider using suction via a deeply advanced Guideliner: you take a properly matched Guideliner (eg, 6 Fr Guideliner in a 6 Fr guide), and you advance it deeply into the thrombus area, then you aspirate via the Tuohy valve. You may even connect the penumbra suction system to the Tuohy while the Guideliner is deep, for stronger suction. 4-For sticky refractory thrombus, may consider intracoronary tpa. TIME trial (JAMA 2019) used slow intracoronary infusion of 10 mg vs 20mg of r-tpa over 5-10 min vs placebo in STEMI after balloon dilatation and before stenting: it showed that r-tpa does not improve eventual flow or outcomes. However, IC r-tpa may be considered for refractory thrombus, using the same 10-20 mg dose, although no data. I would suggest using lower doses, 1-5 mg, administered distally into the thrombus via a dua lumen catheter.

[@user-qc3yc1sw9c]

Very fruitful

[@ap294673]

You are god sent

[@kachiugoani874]

Exactly!!❤❤

[@aymanal_ezair5150]

Very good thanks very much

[@rajthapa1997]

Thank you sir

[@areenal-taie6836]

The best !

[@brahimmhamdi6537]

Thanks a lot

[@Mohamed-cz7kc]

great sir plz sir we are in your experience in cath lab nightmares

[@joepho123]

I have a question Dr. Hanna : if you have a patient come in with cardiogenic shock and STEMI but the chest pain began more than 48 hours ago and found a CTO in the prox LAD would you revascularize?

[@namphan6911]

I'm so glad you did a separate section for RV shock. However, I wonder what is your view on using noradrenaline in cases of right heart predominant cardiogenic shock in AMI? As per your 5 steps in the lecture, usually I have to use a combination of inotropic agents (dobutamine/milrinone) and noradrenaline to keep the MAP ≥ 65 mmHg.

[@eliashanna8248]

Norepinephrine is the best agent for RV shock. I explain that in my book and prior talks, like "Cardiogenic shock" and "Myocardial infarction part 2". In the latter (kzbin.info/www/bejne/b6DVpnaMi9GXr5Y), minute 04:37, I explain why: Since at least half of the RV coronary flow occurs in systole, RV coronary flow depends on the driving gradient between SBP and RV systolic pressure (beside the gradient between DBP and RVEDP) -->RV is very sensitive to decreased SBP, more so than the LV, which may thrive with a slightly reduced SBP (which reduces LV afterload). -->Inotropes used in RV MI should be able to increase SBP, and thus norepinephrine is often the agent of choice

[@namphan6911]

@@eliashanna8248 Thank you Professor!

[@umerqadeer191]

Many thanks for such a great lecture Dr Hanna. Just One more thing how should we proceed, if even after wiring and SC ballon inflation we do not see flow in the culprit vessel? Thank you once again.

[@eliashanna8248]

This a potential stepwise approach: 1-Ensure your wire is in the true lumen, not subintimal. Make sure the tip is moving freely (+/- the wire can move between the main vessel and the side branch anatomy). 2-If the wire feels appropriate, the most common reason for lack of flow establishment after PTCA is that the occlusion extends more distally than you thought. Thus, balloon more distally, and you may use a small balloon 1.5 or 2 mm to balloon distally without risking injuring a vessel segment that you may not stent. You may also just “dotter” the vessel by advancing the balloon catheter distally, without even inflating it. 3-if you still have no flow, it is possible that there is a heavy thrombus burden with distal microembolization =“no reflow”. This may be evident by the angiographic appearance of clot. Consider using IIb/IIIa, esp administered locally via dual lumen catheter. 4-Another very helpful tip at any of the above stages: consider distal contrast injection via a dual lumen catheter advanced distally (1 ml or less, via a small 2 cc syringe). This tells you how big and how open the distal runoff is, and allows you to see that distal vessel if you have not yet. It may show you distal emboli. IT may also show you that your wire is in the subintima (although you should avoid doing it if you already suspect being subtintimal) Evidently do not stent if you have no flow. The only time one may stent with reduced distal flow is when the flow is impaired because of an obvious large dissection he created. I have not found IVUS to be useful in such a case. When there is no flow, you will have heavy blood stasis artifact and the whole image will be muddy.

[@abuahmed9026]

Please dr How to size stent ?? After open total occlusion vessel is spastic and small size how to chosse good size especially LAD ?? 2) in bifurcation lesion thrombus in MV and SB how to mange ?? For SB thrombus how to mange ? Maybe ballon dilatation ( small ballon) or kissing ballon MV+SB for flow SB After stent MV 3) thrombus in MV (bifurcation side) sb sub total lesion without thrombus ? How protect SB with hight risk of occlusion ?? Predilate SB befor MV stenting if disseced what about 02 stent technique ?? What u r opion in this situation not predilate For protection use ballon jalied technique ??

[@khandaitvinod]

Thanks dr Hanna for the excellent update Can you please highlight if there is a place for FFR / IFR in STEMI situation for culprit and non culprit vessels

[@eliashanna8248]

iFR/FFR may have a role for nonculprit stenoses. However, as I indicated at the end of the video, the 2 most important trials of nonculprit PCI, COMPLETE and BIOVASC, mainly relied on angiographic guidance to stent nonculprit stenoses (stent stenoses >70% in a vessel > or = 2.5 mm). They both allowed iFR/FFR use for stenoses 50-70%, but this was rarely done in either trial (70% in a large vessel).

[@khandaitvinod]

@@eliashanna8248 thanks a lot sir

[@wbcjunior]

What advice would you give for stemi involving aneurysm....:

[@eliashanna8248]

STEMI involving aneurysm usually implies heavy thrombus burden. Here are general tips on how to handle heavy thrombus burden that persists or embolizes (macro-emboli) after balloon dilatation: 1-IIb/IIIa inhibitors, consider giving them via distal dual lumen catheter in patients with slow coronary flow 2-Penumbra thrombectomy catheter (Cat Rx) 3-If large thrombus persists, consider using suction via a deeply advanced Guideliner: you take a properly matched Guideliner (eg, 6 Fr Guideliner in a 6 Fr guide), and you advance it deeply into the thrombus area, then you aspirate via the Tuohy. You may even connect the penumbra suction system to the Tuohy while the Guideliner is deep, for stronger suction. 4-For sticky refractory thrombus, may consider intracoronary tpa. TIME trial (JAMA 2019) used slow infusion of 10 mg vs 20mg of IC r-tpa over 5-10 min vs placebo in STEMI after balloon dilatation and before stenting and showed that tpa does not improve eventual flow or outcomes. However, IC tpa may be considered for refractory thrombus, using the same 10-20 mg dose, although no data. I would suggest starting lower doses, 1-5 mg, administered distally into the thrombus via a dua lumen catheter.

[@wilzboyz]

Ikari guides are not very supportive. When I see someone using an Ikari guide they typically have poor catheter manipulation skills.

[@Docsammy]

A tool is as good as the person holding it. I think Dr. Hanna explained his rationale pretty nicely.