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Angioplasty.Org Interview Series: Transradial Approach
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Interview with Sameer Mehta, MD, FACC

Sameer Mehta, MD, FACC, MBA, is Voluntary Associate Professor of Medicine at University of Miami Miller School of Medicine, President of the Indo American Society of Interventional Cardiology, editor of the Cath Lab Digest STEMI Interventions section and author of the Textbook of STEMI Interventions.

Dr. Mehta is considered a pioneer in the specialty of STEMI intervention, the treatment of heart attacks using percutaneous coronary interventions (PCI). He has done groundbreaking work on shortening door-to-balloon times for STEMI interventions and is the course director for LUMEN, the Annual Symposium on Optimal Treatment for Acute MI, now in its tenth year. The 2011 LUMEN course is being held on February 24-26 in Miami, Florida. In this interview, Dr. Mehta discusses the upcoming LUMEN symposium which this year is featuring the transradial (wrist) approach to treating STEMI.

A complete list of educational offerings for the transradial approach can be found on the Transradial Training Courses page in Angioplasty.Org's Radial Access Center.



Sameer Mehta, MD, FACC
Sameer Mehta, MD, FACC, MBA

"I think door-to-balloon times, as challenging as they may appear to some people, are simply the low hanging fruit of STEMI intervention. I truly believe that the greater challenges are legislation and patient education."    

Q: This is the 10th year of the LUMEN course. This is the first year you are featuring the transradial approach. Why now?
Dr. Mehta: Well I'm convinced, mainly because of my international work in STEMI intervention, that we are grossly underpenetrated in our application of transradial STEMI intervention. I think there’s too much resistance, too much lack of awareness and comfort level among interventional cardiologists to try the transradial approach for the rushed door-to-balloon environment that exists in STEMI intervention. If you look around the world, particularly in parts of Asia, as well as in Europe, there is not much hesitation. People actually have a very high level of skills and comfort level in performing their procedures from the transradial route.

One can always argue which is better: going transfemoral gives you more options, but the patient comfort, the decrease in bleeding and early ambulation are clearly the reasons to go transradial.

To further induce the U.S. interventional cardiologists, I thought LUMEN would be a perfect venue to not only have a dedicated workshop, but also to bring in absolute world experts who are recognized for their vast experience and have them demonstrate the techniques, the safety, the application, the methodology, as well as several case presentations to share with everybody.

For example, we have Dr. Tejas Patel of Ahmedabad, India conducting one of the workshops. He conducts the annual TRICO workshop, and it is to his credit that he was the father for most of us in this effort and I think he'll contribute in a very valuable fashion to the meeting.

    LUMEN symposium

"I'm convinced that the absolutely perfect combination for a lot of these patients is going to be transradial procedures performed with bivalirudin. You have the access site which reduces bleeding, as well as a drug which is known to reduce bleeding..."    

Q: You mentioned lack of bleeding complications in the transradial approach. Can you speak as to how this is important specifically in the treatment of heart attack?
Dr. Mehta: We understand that there is a direct correlation between bleeding during the STEMI or even the PCI intervention and long-term mortality. So this is not a small matter to be dismissed as a nuisance or something. Not only do the patients do poorly early on, but there is even an impact on their long-term mortality. So it's something extremely critical and I think the control of bleeding is vital.

I'm convinced that the absolutely perfect combination for a lot of these patients is going to be transradial procedures performed with bivalirudin. You have the access site which reduces bleeding, as well as a drug which is known to reduce bleeding on the basis of the data from the HORIZONS AMI trial. The combination probably represents the most optimal way of performing a STEMI intervention.

Transradial is not going to be for every case, but I think the penetration should increase. The physicians that are performing STEMI interventions should feel comfortable with both techniques. They should also understand that there has to be some very careful triage of patients. Not everybody is going to be suitable for the transradial route. A patient presenting with cardiogenic shock will probably require a right-heart catheterization, will often require an intra-aortic balloon pump or the Impella device. So there has to be a very mature balance in applying these technologies and this is precisely the purpose of bringing in world experts who can share their own experiences.

Q: The treatment of heart attack specifically involves being able to do this very quickly, and reduce the door-to-balloon time. Some cardiologists in the U.S., who work primarily with femoral access, say that transradial takes longer and would present a delay.
Dr. Mehta: I happen to fall in exactly this group. I long have had exactly the same doubts, the same apprehensions, the feeling that you are adding another level of difficulty, another complex variable to an already challenging situation where every minute counts. But we have also learned from the experience of others that once you reach a threshold of expertise, you probably become quite comfortable in doing the procedure without any significant increase in the procedure time. I'll be the first one to humbly acknowledge that there is a genuine apprehension, not unfounded, but I think it is also timely for us to adopt this technology.

Q: Many radial operators use the transradial approach as their default access site ("Radial First"). Does this apply to treating STEMI?
Dr. Mehta: I am not yet convinced of this. I tend to believe that transfemoral should be the preferable technique. I think we are much more used to using it. Our awareness and expertise has been there for many years that provide you greater options for some patients who may have a more difficult clinical presentation and yet I think that one should know both techniques. The sad part is that there are a number of interventional cardiologists who are unable to perform transradial and that is precisely the purpose of mandating and forcing the theme that I have put into this particular symposium.

Q: That being said, is there a specific type of patient where the transradial approach to STEMI is preferable?
Dr. Mehta: I think anybody with lack of access, with severe peripheral vascular disease, is obviously that person. Very obese patients can fall into this group and anybody with a higher bleeding risk. So these are the three or four categories which clearly benefit from a transradial procedure. Once your expertise and skills become good enough, then you're offering them all the additional advantages.

Q: One of the problems, especially in rural areas where patients may be transported from a local hospital by helicopter or ambulance to a hospital with a cath lab, is that those patients are anticoagulated at the initial site and arrive at the cath lab already anticoagulated. Is this a patient that might benefit from the radial approach because of the risk of bleeding complications?
Dr. Mehta: You are absolutely right. In fact you don't necessarily have to go as far into the rural areas. This problem is happening even in the more urban areas where there are issues of transportation and traffic congestion. Patients who are already heavily anticoagulated with IIb/IIIa and antiplatelet drugs with a higher possibility of bleeding, they clearly fall into this group. A lot of these patients have also had lytic therapy, prior to their being transferred, which significantly increases their chances of bleeding.

Q: Beyond discussing the transradial approach, what are the over-riding themes of LUMEN AMI meeting?
Dr. Mehta: This is the tenth year of LUMEN, but the third year where this coronary angioplasty symposium has been converted into a fully subject-centric STEMI meeting. I believe that this is unique. It's probably one of the largest meetings on STEMI globally and I hope that people will come to appreciate and understand both the process and procedure of STEMI intervention which is beyond the aspects of achieving door-to-balloon times. I think door-to-balloon times, as challenging as they may appear to some people, are simply the low hanging fruit of STEMI intervention. I truly believe that the greater challenges are legislation and patient education. At LUMEN we try to educate the attendees with a very global perspective on these matters and bring in a group of global experts on STEMI intervention and hopefully that will be a very worthwhile experience for people to attend.

Q: Door-to-balloon time has been successfully reduced in many hospitals, but the bigger problem may be getting the patients to the door to begin with. Unfortunately too many patients don't realize the important of getting to a hospital that performs angioplasty – they need to be educated on why this is important.
Dr. Mehta: I think it is the responsibility of not only the patient but the very large group of stakeholders who are involved in the care of these patients. Unless there is education and genuine attempts at lowering the true ischemic time, no great purpose is achieved if the patient has had chest pain for six hours and at three in the morning all of us are endangering our own lives, driving at high speeds to come and achieve a door-to-balloon time of 90 minutes. If you add to that the six hours of the patient's chest pain before he presented, not much can gained. So I think all of us need to work harder in educating the patients, whether it is the primary care physicians, the cardiologists, interventional cardiologists, the media, the hospitals -- there is a broad group of people and what could be more important than providing education to a patient where the chances of his not surviving the first hour are pitted against him.

You have struck a very deep chord in the matters you have mentioned about education. I have long been on record about that. If you open up the first volume of my textbook on STEMI interventions, there are areas of huge emphasis talking about the need to educate. I have always recognized that without ER support in advancing this information we are only going to be partially successful.

Dr. Mehta at podium    

Q: How many people do you expect to attend LUMEN AMI?
Dr. Mehta: My guess is that we'll have about 300-400 people. This has been created deliberately not to become a mega-meeting. I think that people who come here are very focused. They are the genuine caregivers, the people who are helping with the logistics of the process, as well as interventional cardiologists who want to come and understand the specific nuances involved with doing a STEMI procedure.

Everybody thinks that achieving the door-to-balloon time is adequate. However, if you don't do a quality procedure, which mandates that there has to be a very selective and comprehensive management of thrombus and management of only the culprit lesion, unless you are able to do a good job and provide the patient with a good quality result, you're just pushing a balloon down an occluding artery and declaring it door-to-balloon success.

I think this is not doing much help to the patient. I also use LUMEN as a caution to all the hospitals who are now in great pursuit of trying to call themselves “Centers of Excellence”. They may be actually achieving the door-to-balloon times, but also have very high false alarm rates and hopefully LUMEN will steer them in the right direction. We also try to focus on and try to foster application of pre-hospital alert.

Q: It really has to be a coordinated effort.
Dr. Mehta: There is a project I would like to mention to you: the PRINCE Working Group, PRINCE standing for Puerto Rican Infarct Nationwide Collaborative Experience. Over the last 8 or 9 months in this project, which is supported by Abbott Vascular, I have personally been navigating and putting together a very committed and very dedicated group of interventional cardiologists and what we have created is probably the world's first and genuinely unique population-based STEMI program in which the all 84 hospitals on the island of Puerto Rico have been converted into a network of either a serving or receiving STEMI hospital and we're trying to create clear lines of unambiguous referrals and achieving door-to-balloon times in a consistent standardized fashion for the entire island. The reason I have a special interest in doing this is I think that at the end of the day, you have to have a more integrated approach how these patients can be treated.

This interview was conducted in February 2011 by Burt Cohen of Angioplasty.Org.