PCI in heart failure

d post-discharge 6-month mortality 
 was significantly higher in pts with HF on admission 
 (20.7% vs 5.9%, p<0.001) 
• Pts with HF who underwent in-hospital revascularisation 
 (predominantly PCI) had significantly lower rate of 
 post-discharge 6-month mortality (14% vs 23.7%, P<0.0001) 
Steg PG et al Circulation 2004; 109: 494-9 
Impact of PCI On Acute Heart Failure Among Patients Hospitalised 
For AMI: Long Term Outcomes by Killip Class 
L Carvalho et al Singapore Cardiac Society Annual Meeting 2014 
A. Mortality curves of patients who underwent PCI 
B. Mortality curves of patients who did not undergo PCI 
Killip I 
Killip II Killip IV 
Killip III 
0.00
0.25
0.50
0.75
1.00
M
o
rt
a
li
ty
, 
%
0 2 4 6 8 10 12
Time (years)
I II
III IV
0.00
0.25
0.50
0.75
1.00
M
o
rt
a
li
ty
, 
%
0 2 4 6 8 10 12
Time (years)
 A B 
Impact of PCI On Acute Heart Failure Among Patients Hospitalised 
For AMI: Long Term Outcomes 
L Carvalho et al Singapore Cardiac Society Annual Meeting 2014 
PCI in Patients with Left Ventricular Systolic Dysfunction: 
Systematic Review and Meta-Analysis 
GB Zoccai EuroInterv 2007; 3: 409-415 
 Conclusions: 
• Low periprocedural morbidity and mortality following percutaneous 
 revascularisation 
• Marked increase in event rate over follow-up, as expected in such high risk 
 patient population 
11 studies including 1284 pts with LVEF <50%. All except one study use BMS 
MACE at hospital discharge MACE at 18 mths followup 
Sardi GL et al Am J Cardiol 2012; 109: 344-351 
Outcomes of PCI Utilising DES in Pts with Reduced LVEF 
• 5377 pts in Washington Heart Centre retrospectively analysed. 
• Pts with normal LVEF (>50%) compared with mild (41% to 50%), 
 moderate (25% to 40%) and severe (<25%) decrease in LVEF 
• Pts with abnormal LVEF were older, more diabetic, renal insufficiency and 
 heart failure syndrome , more angiograpically complex lesions and less freq received DES 
• Primary endpoint: 1-yr MACE all-cause death, Q-wave MI, ST and TLR 
• Primary endpoint significantly increase in pt with lower LVEF (9.7% for normal LVEF 
 vs 20.6% for severely decreased LVEF, p<0.001) 
• Higher ST in pts with lower LVEF (1.4% for normal LVEF vs 6% for 
 severely decrease LVEF, p<0.001), not impacted by DES use 
1 Yr All-cause Mortality 1 Yr Stent Thrombosis 
Death Rates for Patients With and Without Myocardial Viability 
Treated by Revascularization or Medical Therapy 
HR Phillips et al Am Heart J 2007; 153: S65-S73 
PCI In Heart Failure 
• PCI in Heart Failure (Balloon to DES) 
 - feasibility and safety 
• PCI in Heart Failure with Support 
• PCI vs CABG vs Medical Therapy 
BCIS-1 Trial: Elective IABP in High Risk PCI 
Perera D et al JAMA 2010; 304: 867-874 
 Conclusions: 
• Elective IABP did not reduce the incidence of MACCE at discharge 
• Mortality at 6 months was numerically lower in the elective (IABP) group but 
 not statistically significant (4.6% vs 7.4%, P = 0.32) 
• RCT in 17 UK tertiary centres bet Dec 2005 and Jan 2009 
• 301 pts with severe LV dysfunction (EF <30%), extensive coronary disease 
 (jeopardy score ≥8/12) 
TandemHeart Percutaneous VAD 
• Removes oxygenated blood from LA via 
 transseptal cannula inserted through the 
 femoral vein 
• Returns blood via femoral artery 
 Benefits: 
• Reduce preload 
• Reduce ventricular workload 
• Reduce myocardial oxygen demand 
• Increase MAP 
• Improve microvascular and systemic 
 perfusion 
IMPELLA Catheter 
Mounted Micro Axial Flow Pump 
Meyns B et al J Am Coll Cardiol 2003; 41: 1087-1095 
Device Ease of 
Insertion 
Duration of Use Flow
L/min 
Cost Availability 
IABP +++++ DAYS TO 
WEEKS 
  $ ++++ 
IMPELLA 
2.5 
 ++++ HOURS TO 
DAYS 
2.2 
 $$ + 
CPS +++ HOURS 4-5 $$ + 
LVAD + WEEKS TO 
MONTHS 
 5-6 $$$$$ + 
REITAN ++++ HOURS TO 
DAYS 
 2 ? _ 
PTVA 
TandemHt 
 +++ DAYS TO 
WEEKS 
 5.0 $$ + 
Mechanical Circulatory Support in Cardiogenic Shock 
MetaAnalysis RCT of Percutaneous Left Ventricular Assist Devices 
versus IABP for Treatment of Cardiogenic Shock 
JM Cheng et al CRT 2009 
Thiele et al Burkhoff et al Seyfarth et al 
LVAD TandemHeart TandemHeart Impella LP2.5 
Control IABP IABP IABP 
N of patients 41 33 26 
Setting Single-center Multi-center Two-center 
Inclusion period 2000-2003 2002-2004 2004-2007 
Randomization Yes Yes Yes 
Results: 30-day Mortality 
Percutaneous LVAD patients had similar mortality as IABP 
0.1 1 10
0.95 (0.48 ; 1.90)
1.33 (0.57 ; 3.10)
1.00 (0.44 ; 2.29)
1.06 (0.68 ; 1.66)Pooled
Favors LVAD Favors IABP
30-day mortality
Relative Risk
9/21 9/20
LVAD
n/N
IABP
n/N
9/19 5/14
6/13 6/13
24/53 20/47
P(heterogeneity) = 0.83
I2 = 0%
Burkhoff et al.
Seyfarth et al.
Thiele et al.
JM Cheng et al CRT 2009 
PCI In Heart Failure 
• PCI in Heart Failure (Balloon to DES) 
 - feasibility and safety 
• PCI in Heart Failure with Support 
• PCI vs CABG vs Medical Therapy 
Role of PCI vs CABG 
• No clinical trial comparing revascularisation with CABG or PCI 
 of patients with heart failure and reduced ejection fraction exists 
• All available data comparing the revascularisation of such patients 
 comes from large observational studies 
Effect of Heart Failure on Long Term Mortality 
After Coronary Revascularisation (BARI Trial) 
EM Holper et al Am J Cardiol 2007; 100: 196-202 
3133 pts from BARI randomised trial and registry included 
 Results: 
• 10 years after initial revascularisation, cumulative rates of 
 freedom from cardiac death were 
 - 90% in pts without HF 
 - 75% in pts with HFpEF 
 - 59% in pts with HFrEF (p<0.001, 3-way comparison) 
• In diabetic pts with HFpEF, there was a significant increase in 
 cardiac mortality compared with pts without HF (p<0.001) 
 AWESOME: PCI vs CABG in Pts with Medically Refractory 
Myocardial Ischemia & Risk factors for Adverse Outcomes with Bypass 
• 232 pts randomised to CABG and 222 to PCI (POBA) 
• Has 1 or more risk factors for adverse outcome with CABG: prior open-heart 
 surgery, age > 70yrs, LVEF <0.35, myocardial infarction within 7 days or IABP required 
Morrison DA et al Am Coll Cardiol 2001; 38: 143-9 
3-year survival for 
CABG and PCI 
were 79% and 80% 
respectively (p=0.46) 
Survival free of UAP 
(p=0.16) 
HEART (Heart Failure Revascularisation Trial): 
Conservative vs Invasive (PCI or CABG) in Heart Failure Pts 
Cleland JGF et al Eur J Heart Failure 2011; 13: 227-233 
• Patients with heart failure, CAD, and LVEF 35% who had substantial volume of 
 viable myocardium with contractile dysfunction assessed by standard imaging technique. 
• Only 138 of planned 800 pts enrolled because of funding withdrawal due to slow recruitment 
At median 59 mths, mortality rates of 
37% in conservative vs 38% invasive group 
Conclusion: Conservative strategy may not be inferior to 
revascularisation in patients with heart failure. However, 
study was underpowered 
Registry Studies 
O’Keefe JH et al Am J cardiol 1993; 71: 897-901 
Balloon Angioplasty vs CABG for Multivessel CAD With LVEF 40% 
Single centre (Mid America Heart Institute) , 100 consecutive pts who underwent CABG 
matched with cohort of 100 PTCA pts bet Feb 1985 and Sep 1988 
Long term survival 
Survival by extent of revascularisation 
 Results 
• Early results favoured angioplasty: 
 Similar mortality (3% vs 5%); 
 shorter in-hospital stay (4.3 vs 12.8 days) & 
 less stroke (0% vs 7%) 
• Late follow-up favoured CABG: 
 Trend towards improved survival 
 (76% vs 67%, p=0.09) 
 superior relief from angina (99% vs 89%) 
 less repeat revascularisation (0 vs 50%) 
New York Cardiac Registries 
Rouleau JL et al Can J Cardiol 2014; 30: 281-287 
• 37 212 pts with multivessel CAD who underwent CABG compared 
 with 22 102 pts who underwent PCI from Jan 1997 to Dec 2000 
• Pts with LVEF <40% and 2-vessel CAD, but 
 without proximal LAD disease, more 
 frequently received PCI than CABG, and had 
 similar outcomes 
• When pts had 2-vessel CAD with prox LAD 
 disease, or 3-vessel CAD with or without prox 
 LAD disease, they more frequently had CABG 
 and with better survival 
• Difference in survival remained after adjusting 
 for other risk factors 
BJ Gersh et al N Engl J Med 2005; 352: 2235-2237 
Difference in the Approach to the Lesion with PCI and CABG 
PCI targets at the ‘culprit’ lesion or lesions, where CABG is directed at 
the epicardial vessel, including the ‘culprit’ lesion or lesions and future culprits, 
a difference that may account for the superiority of CABG 
2011 ACCF/AHA/SCAI Guideline for PCI: 
Revascularisation to Improve Survival Compared with Med Therapy 
2011 ACCF/AHA/SCAI Guideline for PCI J Am Coll Cardiol published online Nov 7, 2011 
ESC Committee for Practice Guidelines Online Publish 19 May 2012 
ESC Guidelines 2014: Recommendations for Myocardial Revascularisation 
In Patients with Chronic HF and Systolic LV dysfunction (EF ≤35%) 
Consideration of Various Clinical Variables When 
Recommending Best Therapeutic Options 
Color blue favours medical therapy alone, and 
colour red favours surgical therapy in addition to medical therapy 
Rouleau JL et al Can J Cardiol 2014; 30: 281-287 
Conclusions 
• Revascularisation decisions in patients with HF cannot be 
 based on randomised clinical trial data 
• Revascularisation is reasonable in pts with HF who have 
 appropriate coronary anatomy, substantial myocardium in jeopardy 
 and no contraindications 
• Viability testing can identify pts who may have hibernating or stunned 
 myocardium, and may play a supportive role in decision making 
• Choice of revascularisation technique should be made on the basis of 
 anatomical, clinical and patient preference issues 
• Ability to achieve complete revascularisation is an important 
 consideration beyond just types of method (PCI vs CABG)