Hello, everyone, and welcome to the Journal of the Society of Cardiovascular Angiography and Interventions, Conversations in Interventional Cardiology. My name is Sandeep Nathan. I'm an interventional cardiologist and professor of medicine at the University of Chicago Medical Center in Chicago, Illinois, and an associate editor for J-Sky. I'm honored to represent J-Sky and Editor-in-Chief Alexandra Lansky for today's edition of Conversations in Interventional Cardiology. We're here today to discuss a very important document that was just published in J-Sky titled Sky Expert Consensus Statement on the Management of Patients with STEMI Referred for Primary PCI, and I'm joined today by an esteemed panel of leaders and experts. The presenting author for today's discussion is Dr. Jacqueline Tammes Holland, who's an interventional cardiologist at the Cleveland Clinic Heart, Vascular, and Thoracic Institute. Welcome, Jacqueline. Thank you. Panelists are Dr. Sanjit Jalli, professor of medicine, McMaster University, Hamilton, Ontario, Canada. Welcome. Thank you. And Dr. Cindy Grimes, who's the chief scientific officer at Northside Hospital Cardiovascular Institute in Atlanta. Welcome, Cindy. Thank you. So I think I'll turn it over to Dr. Tammes Holland to get us started with a brief overview of the document. Jacqueline? All right. So first of all, Sanjit, thank you so much, and thanks for inviting me to be here. I'm really excited to be able to talk to you about our document, and obviously I'm doing this on behalf of all of my co-authors. So this sort of the journey of this document started about two years ago when we were sort of discussing among ourselves the different ways to sort of approach aspects of care in STEMI, whether it be do you go up first with the guide, and then do you take pictures of the rest of the coronaries later, or how do you manage no reflow? And we realized that there's a lot of unanswered questions, and there's very little in the clinical practice guidelines to guide the interventional cardiologists on what best to do in the cath lab, because a lot of the guideline focuses on sort of the patient-focused care and not so much on technical aspects of the cath lab. So we decided to put together a document to sort of discuss this, and the idea of the document is that we realize there's no real right or wrong in terms of doing something. There's a lot of differences of opinion. So we brought together a group of incredible experts, and my co-authors are amazing, to sort of discuss their experiences and what they think is best. My favorite part of this document are the key consensus points. As people will say, it's a detailed document. There's a lot to sort of digest in one setting, but the key consensus points really allows you to get a summary of the different aspects of the areas in the document that we feel are really important. So in order to be a key consensus point, we used a modified Delphi approach, and you needed at least 80% of the writing committee members to vote on the recommendation—not the recommendation, because it's not a guideline—to vote on the consensus, and then at least 75% had to be in consensus and agree with that aspect in order for it to be a key consensus point. So these are the things that, while there are some areas where we feel you can do different approaches, these were the points where we felt were really important and salient key points for the interventional cardiologist to take home. So we begin our documents by discussing the importance of cath lab team readiness, and we talk about time-to-treatment goals. These are not new. These are guideline recommendations for time-to-treatment that are out of the clinical practice guidelines, but what we really wanted to do is to sort of focus on the various little aspects of time-to-treatment for each stage of the presentation. So regardless of how the patient presents, we want people to realize that there are different time-to-treatments, whether it's somebody coming in through EMS to a PCI hospital, whether it's somebody walking in directly to a PCI hospital, or whether it's somebody coming to a non-PCI hospital. There are different time-to-treatments and ways in which you can expedite care. We went on to talk about the key factors that we felt were really important for timely reperfusion, and we emphasize this because we feel it's very important. Medical activation should be of the cath lab, not just notifying the ED that you're coming in. There should be a single page to all team members. Ideally, we should be getting EKG transmission, and that EKG should be transmitted to the cath lab team members' phones. It should not be just going to the ED and then just nobody from the cath lab team sees. We feel emergency department bypass is really important. It has shown a great way of decreasing times in patients who are totally straightforward, and you know they're going to not need to stop in the ED for anything. Then there should be expectations for timely arrival of the cath lab staff. We then go on to discuss the optimal arterial access. In the ACC AHA guidelines, it's a class one recommendation to do radial artery access, and we feel that that should be the default strategy in patients with STEMI. However, we do also realize that there are extenuating circumstances in which femoral artery access might be used, and we certainly don't want people struggling to try to get radial artery access in situations where it's going to be impossible to get, such as somebody with a left radial artery that was to use for a bypass graft and you need to get a LEMA graft. There's no point in trying to go left radial with that, so we really wanted to emphasize that there are situations in which you might use femoral artery access, and that's okay in those situations. We talk a lot about managing thrombus, and here's where there's no right or wrong answer. There's very little data in randomized clinical trials about the approach to thrombus that have been positive in terms of randomized data, so we really just talk about all the different approaches to managing thrombus. We do talk a lot about aspiration thrombectomy because we feel it's important, and even though the guidelines give it a class three, that's for routine use, so we do discuss the use of aspiration thrombectomy as well. So a lot of different key points about how best you can manage thrombus, but there was really no one takeaway that you have to do it this way because there are differences of opinions, and when you talk about a case, there's a lot of different ways to approach it. Then we went on to talk about managing no-reflow, and as you can see, the emphasis was on arterial vasodilators. We talked about prevention of no-reflow as one of the single best ways to manage no-reflow, but we also emphasized the use of arterial vasodilators and the delivery of these drugs to the distal artery. We give suggested dosing for intracoronary vasodilators. Everybody has their own little cocktail that they use, but we just sort of gave sort of instances where you need to be cautious with the use of those agents and the particular dosing that you might want to use. The clinical practice guidelines give a class 2A recommendation for intravascular imaging overall, and we really feel that intravascular imaging is in particularly extremely important, especially in patients with STEMI when you've had stent thrombosis and other situations. So we do place a lot of emphasis on the use of intravascular imaging and highlight the importance of doing your pre-PCI imaging to understand the arterial sizing or at least pre-stent imaging and post-PCI imaging to be sure you've had maximal expansion and apposition. Then we go on to talk about special circumstances, such as what do you do in patients with cardiogenic shock? How do you manage patients post-lytic? What do you do when you have multi-vessel disease in a patient with STEMI? What do you do when you have a bypass graft involvement, a patient with STEMI with a bypass graft that's occluded, and how do you manage stent thrombosis? We talk about anatomical considerations, including STEMI that involves a bifurcation lesion, STEMI that involves a severely calcified vessel, and aneurysms and ectasias. And then we go on to talk about the non-atherosclerotic causes of STEMI. We end our document in discussing future directions, including the use of AI to potentially help us detect occluded arteries beyond the usual ST elevation criteria on EKG. What do we do with late presenters who are coming in late? Are there better ways of managing these patients? We hope there could be future research on that. And finally, the importance of decreasing infarct size. A lot of infarct size is related to microvascular obstruction. We talk about the importance of using tools to predict microvascular obstruction in the cath lab rather than later on after you've done your MRI to see if we can identify tools to use to decrease the infarct size. So I hope you guys enjoy the document. A big thank you to all of my co-authors, again, amazing leaders in the field, amazing experience with STEMI care, and really great to get their input on how best to manage this. I'd like to thank Sky Leadership. They have been absolutely amazing. Just overall, they're always trying to produce documents that are useful for the interventional cardiologist, and they allowed us to go ahead with this document. Scott and Chelsea were fantastic, and we went through a series of different presidents throughout the time this document was being produced, so thanks to all of them. And finally, thank you so much to J. Sky for allowing me to be able to present this, and most importantly, for publishing our document. Wonderful. Jacqueline, thank you so much for the capsule summary. I think that it sort of hits the high points, but just to tell all the listeners and readers of J. Sky, there's so much important information in this document. I'd recommend everyone sort of read it cover to cover. Maybe we'll get started just asking the panelists about what they thought was the sort of most important takeaway for the practicing interventionalist. Dr. Jolly, I'll start with you. I have some biases, obviously. Transrenal access, I think, is the default approach in STEMI, and I think certainly we've hit 50% in the U.S., which is a milestone, but we've still got a ways to come, so I think that's very important. And I think the next generation of interventional cardiologists have really taken that and taken it forward, but is getting everyone comfortable and up to speed with that, whether you've been practicing for 30 years or you've been practicing for six months. I think the second thing is microaxial pumps, right? The danger shock just came out, and the fact that you had this in the guidelines is a kudos to the committee, right? A lot of committees say the document is sealed. I'm not going to name organizations, but a trial comes out, we cannot turn the guidelines and change them, or a consensus document. And so kudos to the group here and the writing committee for saying, you know what? We're going to include this. This is important. And I think, you know, irrespective, every cath lab probably in the country or across different geographic regions needs to have protocols with regards to shock, and they need to be updated based on the danger shock criteria. So I think that's really, really important. And I don't think you can get away with, you know what, I'm just going to put a balloon pump and reassess in the morning, and I think that's no longer acceptable care. And then, you know, the other takeaway, and that's maybe my bias, because the complete trial came out of our center, but, you know, this idea that multivessel disease, you need to revascularize, for the most part, because it prevents recurrent events. And so having a thoughtful, you know, approach to multivessel disease, now whether you do it in hospital, you stage it a few weeks later, and, you know, providing complete revascularization in STEMI. There, you know, all those three points, we have a very good evidence base, you know, they're virtually class one recommendations in the guidelines. And it's often said, you know, if you can only pick out three things, that's what you should do. Because, you know, interventional cardiologists have very low attention span. We're like ADHD kids, right? And it's funny, because in the guidelines, we gave it a class one, but we actually give it a class one for radiolary access and experience centers. And I feel like you need to get rid of that, because everybody should be experienced at this point. And I'm one of those old dinosaurs that really transitioned over in like 2015. And it took me, you know, it took me a while to get there. But you know, by 2000, whatever, 17, you were just, you know, you're just couldn't even believe you did femoral access first year. Right, you tend to forget from our access after a while. But I do think it's easier in an academic center when you're training fellows and the fellows can cross fertilize the tendings. If you are in an established practice, where you trained 20 years ago, it's going to be difficult. So I think it's not unreasonable. I think there's expectations, but, you know, they might be better at femoral than they are at radial. Yes, yeah, I agree. I agree. And it was easy for me to learn because my fellows were with me every step of the way we were learning together. Right, exactly. Well, from my standpoint, I think it's amazing that you did this. And I think it's great that you're putting in so many practical tips, because that's what SCI is all about. And unfortunately, the guidelines don't address anything that's not part of a randomized clinical trial. And I found that your dosing chart for the intracoronary vasodilators is really key. It'd be great if all the cath labs could hang that in the lab because so many times your face, you're two in the morning and your face with no reflow. And what are you going to do pull out your phone and Google the doses of these, particularly the intracoronary epinephrine? I mean, I use that a lot when patients are hypotensive, but you know, many people don't feel comfortable using that at all. So I think that is very key. And then it's interesting your concepts about thrombus management. I mean, I actually believe the same thing you need to cross it with the wire, you need to define the size of the thrombus because a totally occluded vessel could be just a single platelet doing that. More could be a huge thrombus. And I think all of us would agree that you would manage that patient differently. In the absence of data, we don't really know whether what we're doing is correct. But if you have a consensus agreement, at least you have some, you know, some other people backing some of your choices. So I think that's great. And I'd like to you know, it's interesting to the no reflow part of it because when we did the first stenting in ketamide was a stent PAMI trial. And we were using the was randomized to blue angioplasty versus stenting using the J&J heparin coated stent. It's big bulky stent and what we found is post dilation of that stent caused a lot of no reflow. And I think this no touch technique or direct stenting, you know, that's what a lot of people across the world are doing now. Did you talk about that at all, Jacqueline? We do. And actually, if you look at that figure on the left side, it says consider direct stenting. And it's very interesting, because, again, that's why I love this panel, because you had different viewpoints, and there was concern about direct stenting, and you end up under expanding your stent, because there's some calcification. And then there was a lot of people who do exactly that and go for direct stenting, and they really have no problem with no reflow. So there was a lot of differences of opinion. And that's why it was sort of like, mentioned, and it's in the figure as one option for, you know, managing thrombus and just going in with a direct stent in those cases where there's not a tremendous amount of thrombus and going ahead. Right, right. And then with regard to imaging, you know, I have these anecdotal cases where you, you know, all of us have seen patients where you put a stent in and the vessel was really small in the midst of the stomach, and you bring them back later, and it's a gigantic vessel. So how would you I mean, I'm not sure that doing an IVAS or an OCT would have told me that, because the whole vessel is diffusely, you know, at the time. And so are you recommending copious amounts of intracoronary vasodilators? We are, we encourage use of nitroglycerin. So then that way you you know, you don't get so much spasm. You know, I, you know, when you talk about the data, it's very interesting, because if you look at the data, there's not that much data on STEMI and the use of intracoronary imaging. So we extrapolated the, you know, our emphasis on intracoronary imaging from the data, which is really in either AMI patients who aren't STEMI. But I, we do encourage the use of vasodilators there. And, you know, and I think that you can, hopefully you can at least estimate to some degree, or at least you can see if you're, if it's, if it's well expanded and well opposed. So. Well, thank you all for, for those insights. Jacqueline, let me ask you about Table 1, which is the toolbox. I think that's such a great addition to the document. And it really kind of lays out all of the basics. Now, you know, we all work in university labs, or, you know, tertiary coronary care centers, where we have, you know, all the toys and multiple, you know, multiple versions of every toy. And it's only when you go out into the community, where a lot of STEMIs present, that you realize that you're working with sort of a limited toolbox. So my question to you, I guess, is, how do you get community labs to sort of adopt one of each of these and become comfortable also with intravascular imaging, which is, you know, still vastly underutilized in straightforward PCI, let alone STEMI PCI? Yeah, that's a great question. And I think that the purpose of this toolbox was to emphasize, I think when you're in a smaller lab, you have the ability during the day to pick and choose which cases you're going to embark on. And if you don't feel comfortable, that's perfectly fine. And you can transfer to your tertiary care hub hospital to do that complex left main bifurcation. But if you are selling yourself as a STEMI center, you don't get to pick and choose who comes to your hospital. They could be somebody with severely calcified lesions, they could be somebody with severely tortuous, and you need to be prepared to encounter those cases. And you need to have the tools available to do that. And so we really weren't intending on policing anybody to say you should or shouldn't be doing primary PCI or whatnot. But the concept is, is that you might say, well, I never need that those delivery catheters, or those guide extensions, because I never do those calcified complicated lesions. But you really do need to be familiar with how to use it, and use it for those cases that if you're going to do a case in the middle of the night, you can help help the patient and do it. So you need to be familiar with some of the with these tools. And we sort of gave at least one from each category, we didn't say you had to have every tool, but you need to be familiar with the tools because you should be able to take care of any complexity of a STEMI in the lab. Otherwise, you shouldn't hang your hang your sign up as your STEMI center. Let me ask another question. It feels like and I have an obvious bias here invested in the cardiogenic shock space, but it feels like 2023 into 24 is kind of like the, you know, the time of a lot of movement in the in the cardiogenic shock space with microaxial flow pumps. And, and, you know, even beyond that, we saw three important sub analyses of danger shock at TCT this year. And so balloon pumps are still listed in there, as have one device, at least one device, one or more, right. So balloon pump, microaxial flow pump, ECMO, do you think balloon pumps still have a role? If the intention is to do the STEMI and then ship the patient over to the hub hospital? Or, you know, should the focus really the attention and the and the effort really go towards getting comfortable with putting in impella and discerning who the right person is for, you know, for placement of a an impella device? Yeah, I think it depends on the center, I'd love to hear everybody else's opinion. But in my opinion, I feel that you have to do enough of a volume to be comfortable with the insertion of these large bore axis. And so we didn't really want it to be that you do, you know, you do your whatever you do your 50 cases a year, and you have, you know, that one impella that you're inserting each year, you know, like you said, they're better off being transferred to the hub center and getting the full gamut. But there are situations where perhaps they can't really, you know, they need some sort of support until they get there. And that's why we put balloon pump, obviously, if you're at a center, that perhaps you don't do a whole lot, but your your operators are very comfortable with large bore access, and they can do it, then, then I think, obviously, you should be putting in the bigger device and the better device. But I think it really depends. And so we didn't, again, we didn't want to say you, you have to have an impella on in your cath lab, if you're not going to be using it correctly. I think, you know, you have to be careful about those really small centers that don't do that many studies. Yeah, especially since everybody's going to be doing radio, right? And you forget how to even obtain femoral access. So, yeah, that's, that's difficult. So I think having if you're one of the hub and spoke situations, you really need to have a very good transport team too, because, you know, the impella can get dislodged very easily if it's placed. Where I work, there's a lot of impella placement at the smaller hospitals, and they get transferred in because the difficult part for them is the CCU management. There's nobody there to take care of that impella, whereas in the cath lab, most of the people can insert it pretty easily. But that's not true for all cath labs, obviously. Sanjeev, can I ask you, in Canada, what is the practice with respect to use of micropuncture and, and ultrasound when you when you have to have femoral access? Is that widely implemented? Or is that sort of selectively? You know, it's interesting, because we've presented a late-breaker, I think two years ago, TCT, the universal trial where we randomized about, I don't know, 600-700 patients, ultrasound guidance. And what we found is that we found like similar to the rival trial, we like radial versus femoral access is that as you do a clinical trial, it really shifts the culture. So we've really shifted in, we've seen in Canada that, that we're primarily we're like 90% trans radial across the country. And, but that's also shifted, we're probably not as good as femoral. And then when we do with femoral, it's, you have to do it carefully. And there's some controversy about the value of micropuncture in terms of the randomized evidence. So there's, there's, there's, you know, that I would say is is inconsistently used, but ultrasound, I think, has really grown in its use. And you know, what's interesting is, it also allows you not only to pick the right area to puncture, choose the right artery, but perhaps with closure devices, you can pick an area without calcium. And so particularly, if you're gonna do large bore access, like a, a microaxial pump, you're going to pick a spot in the artery that you can pre-close, and then prevent complications, you know, once you're ready to take that microaxial pump out. Yeah, great. And so I think we're getting close to time. Cindy, you were at the vanguard of primary PCI when, when a lot of this started. So, so you get the final word on this, on this document. Any, any last thoughts or comments to share? No, I just think that it's great that you're putting this together. It's going to be incredibly helpful to the practitioner, and a spectacular job to all. Wow, thanks. Coming for you. That's wonderful. Thank you so much. Well, I think that's about all the time we have. Thank you all. Jacqueline, thank you so much for presenting this document and leading the charge on this. Cindy, thank you so much. And Sanjeev, thank you for participating in this conversation in interventional cardiology.

STEMI

Primary PCI

Thrombus Management

Intravascular Imaging

Microvascular Obstruction

Cardiogenic Shock