The success of primary PCI is defined on the basis of acute vessel opening and deployment of stent and wheeling out the patient out of the cath lab. Most PCI cath report promptly mentions TIMI 3 flow with Grade 3 myocardial blush.
I recently encountered 3 patients over a period of 2 months in my echo lab. All three had a recent primary PCI for STEMI found to have scarred IAS with moderate LV dysfunction.
These patients were medically savvy and asked a simple question after glancing at the report signed by me.
Doctor , If my myocardium has been allowed to die a silent death in a matter of 30 days and replaced by a whitish scar , what is the point in calling the much hyped primary PCI successful and charging me about 4 Lakh Rs . They wanted to know ?
I told them you have to direct this query o the supposed state of the cardiac Intervention team.I also told them it may not be proper to criticize anyone. The science of myocardial revascularisation is yet to be fully understood.
Why the myocardium goes for long-term scarring in spite of prompt early revascularization?
- Time window errors (What you think is early PCI may be in fact a late one!)
- Intermittent patency
- Re- occlusion
- Individual variation in hypoxia resistance
- Contra-lateral significant CAD.
- Recurrent coronary events
- Poor compliance with medications.
Final message
Just because your patient has received a state-of-the-art primary PCI in a high-end hospital does not negate the possibility of myocardium going in for scarring and resulting in significant LV dysfunction. There is something more hidden in coronary hemodynamics than it appears!
The so-called acutely successful PCI in your discharge summary actually may mean nothing. Unfortunately, we the pundits of cardiologists never bothered to include myocardial status as one of the criteria to define the success of the procedure.
Ideally, we may defer calling a primary PCI successful or not by at least a few months, when the true story unfolds ie how your myocardium has responded to the treatment and the after-effects of a stent.
Dr.S.Venkatesan MD 