B.G. 62 aa.
Fumatore attivo, IA, dislipidemia
2009
SCA Malattia a. circonflessa : PTCA con stent “metallico”(BMS)
27/12/2013
Ricovero programmato per TE positivo 75 W
28/12/2013
Coronarografia : restenosi subocclusiva intra-stent arteria circonflessa
prox ; lesione 50% c destra ; IVA “irregolarità”
Angioplastica
PCI: impianto di DES (tecnica “stent in stent”)
30/12/2014
Dimissione . Asa 100, Clopidogrel 75, bisoprololo 2,5 , atorvastatina 20
B.G. 62 aa.
05/01/2014
ore 14:00 dolore tipico a riposo
ore 14:30 giunge in DEA (Pescia)con mezzi propri (!)
B.G. 62 aa.
05/01/2014
ore 15:30 entra in Sala di Emodinamica al San Jacopo
Coronarografia per via radiale destra
Diagnosi:
Occlusione trombotica
in ingresso stent:
“Trombosi Subacuta di Stent”
Trattamento :
In DEA :eparina 5000 U ev
In Emodinamica
Carico orale Prasugrel
Avanzato catetere Export:
Reo-Pro (Abcximab) i.c.
&
Trombectomia manuale
Fine art of thrombus suction in STEMI !
February 29, 2012 by
dr s venkatesan
B.G. 62 aa.
05/01/2014
ore 15:45 Trombectomia
B.G. 62 aa.
05/01/2014
ore 15:50 ripristinato flusso TIMI 3
2)Trattamento:
PTCA palloncino ,
con distensione
alta pressione
dello stent
B.G. 62 aa.
05/01/2014
ore 17:00 in reparto Liv 1 S.I.
Stent Thrombosis
(ARC Definite + Probable)
3
Any Stent at Index PCI
N= 12,844
Endpoint (%)
Clopidogrel
2.4
(142)
2
1.1
(68)
1
Prasugrel
HR 0.48
P <0.0001
NNT= 77
0
0 30 60 90
180
270
Days
360
450
RIVAL
RIVAL Study Design
NSTE-ACS and STEMI
(n=7021)
Key Inclusion:
• Intact dual circulation of hand required
• Interventionalist experienced with both (minimum 50 radial
procedures in last year)
Randomization
Radial Access
(n=3507)
Femoral Access
(n=3514)
Blinded Adjudication of Outcomes
Primary Outcome: Death, MI, stroke
or non-CABG-related Major Bleeding at 30 days
Jolly SS et al. Am Heart J. 2011;161:254-60.
RIVAL
Site of Non-CABG Major Bleeds
(RIVAL definition)
*Sites of Non Access site Bleed: Gastrointestinal (most common site), ICH,
Pericardial Tamponade and Other
RIVAL
Results stratified by
High*, Medium* and Low* Volume Radial Centres
*High (>146 radial PCI/year/ median operator at centre), Medium (61-146), Low (≤60)
Tertiles of Radial PCI Centre Volume/yr
p-value
Interaction
0.021
HR (95% CI)
Primary Outcome
High
Medium
Low
Death, MI or stroke
0.013
High
Medium
Low
Non CABG Major Bleed
High
Medium
Low
0.538
Major Vascular Complications
0.019
High
Medium
Low
Access site Cross-over
0.003
High
Medium
Low
No significant interaction by
Femoral PCI center volume
0.25
1.00
Radial better
4.00
Femoral better
16.00
Impact of Therapies on Outcomes
Ischemic events:
MI/CKMB↑
Stent Thrombosis
Bleeding
Bleeding and Mortality
Major Bleeding
Hypotension
Cessation of
ASA/Clop
Transfusion
Ischemia
Stent Thrombosis
Inflammation
Mortality
Bhatt DL. In Braunwald EB, Harrison’s
Online. 2005.
HORIZONS: 1-Year All-Cause Mortality
Bivalirudin alone (n=1800)
5
4.8%
Heparin + GPIIb/IIIa (n=1802)
Δ = 1.4%
Mortality (%)
4
3.4%
3
3.1%
2
2.1%
HR [95%CI] =
0.69 [0.50, 0.97]
Δ = 1.0%
P=0.049
1
P=0.029
0
0
1
2
3
4
5
6
7
8
9
10
11
12
Time in Months
Number at risk
Bivalirudin alone
Heparin+GPIIb/IIIa
1800
1802
1705
1678
1684
1663
1669
1646
Mehran R et al. Lancet 2009:on-line
1520
1486
HORIZONS: 30 Day Adverse Events
30 day event rates (%)
12
Heparin + GPIIb/IIIa inhibitor (N=1802)
Bivalirudin monotherapy (N=1800)
P<0.001
10
8.3
8
6
4.9
P = 0.90
4
2
1.8
1.8
0
Reinfarction
*Not related to CABG
** Plat cnt <100,000 cells/mm3
Major bleeding*
Stone GW et al. NEJM 2008;358:2218-30
MATRIX Trial
NCT01433627
NSTEACS or STEMI with invasive management
Aspirin+P2Y12 blocker
1:1
Trans-Radial
Access
Trans-Femoral
Access
1:1
Bivalirudin
Heparin
Mono-Tx
±GPI
1:1
Is TRI superior to TFI ?
Stop
Infusion
Prolong≥ 6 hs
infusion
http://www.cardiostudy.it/matrix
Is Bivalirudin superior to UFH ?
Should Bivalirudin be prolonged
after PCI ?
Trattamento delle SCA
paziente
Rischio ischemico
vs
Rischio emorragico
procedura
Accesso
Trombectomia
Stenting
IABP
Nuovi devices
farmacologia
ASA +Clopidogrel
ASA + nuovi bloccanti 2Py12
Uso selettivo dei GP2b3a
Eparina vs Bivaluridina
B.F. 76 aa
Familiarità per CI, IA, DM tipo 2, dislipidemia
25/10/2013: dolore toracico tipico insorto a riposo
FMC (118) ad un ora circa dall’esordio .
Diagnosi ecg di IM anteriore (ST sopra V2-V5)
“door to balloon (D2B)” time di 75 min
Coronarografia : stenosi “significativa” TC,
occlusione trombotica di IVA, stenosi critica 75%
“ulcerata” di C.dx prossimale, arteria CX indenne
B.F. coronarografia sinistra
Stenosi TC
Occlusione IVA
B.F.Angioplastica primaria tramite trombectomia
ed impianto di stent (DES)
IVA
B.F….Ad un mese (11/12/2013) controllo con “IVUS” su TC …..
Stent di IVA
Stenosi TC
IVUS : intra vascular ultra sound
….Ad un mese (13/12/2013) controllo con “IVUS” su TC….
Stent di IVA
Stenosi TC
IVUS : intra vascular ultra sound
….Ad un mese controllo con “IVUS” su TC : MLA 4,2 mm2
Stent di IVA
Stenosi TC
Area luminale minima 4,2 mm2
Valori cut off per TC 6,0 mm2
IVUS : intra vascular ultra sound
B.F. (14/12/2013) PCI di TC mediante impianto di stent su TC-IVA
Stent su TC
Stent su IVA
B.F. (13/12/2013) PCI di TC mediante impianto di stent su TC-IVA
25/10/2013
Stent su TC
Stent su IVA
PCI di c destra con impianto di stent DES 1° tratto
Stent su C destra
Ottimizzazione tecnica impianto “Clear Stent”
Stent C. destra
PROVE-IT TIMI-22
Death, MI, UA requiring hosp,
revasc >30d, or stroke (%)
4,162 Randomized Pts with ACS
30
26.3%
Pravastatin 40 mg/d
25
22.4%
16% RR
P = 0.005
20
Atorvastatin 80 mg/d
15
How many events were attributable to:
1) Restenosis, stent thrombosis, etc. vs.
2) Significant disease left behind, vs.
3) VP with rapid lesion progression?
10
5
0
0
ACS
median 7d
PCI 69%
3
6
9
12
15
18
21
24
Months of Follow-up
Cannon CP et al. NEJM 2004;350:1495-1504
27
30
The PROSPECT Trial
Background
• We therefore performed a prospective,
multicenter natural history study using 3 vessel
multimodality intracoronary imaging to quantify
the clinical event rate due to atherosclerotic
progression and to identify those lesions which
place pts at risk for unexpected adverse
cardiovascular events
The PROSPECT Trial
700 pts with ACS
UA (with ECGΔ) or NSTEMI or STEMI >24º
undergoing PCI of 1 or 2 major coronary arteries
at up to 40 sites in the U.S. and Europe
Metabolic S.
• Waist circum
• Fast lipids
• Fast glu
• HgbA1C
• Fast insulin
• Creatinine
PCI of culprit lesion(s)
Successful and uncomplicated
Formally enrolled
PI: Gregg W. Stone
Sponsor: Abbott Vascular; Partner: Volcano
Biomarkers
• Hs CRP
• IL-6
• sCD40L
• MPO
• TNFα
• MMP9
• Lp-PLA2
• others
The PROSPECT Trial
3-vessel imaging post PCI
Culprit artery, followed by
non-culprit arteries
Angiography (QCA of entire coronary tree)
IVUS
Virtual histology
Palpography (n=~350)
Meds rec
Aspirin
Plavix 1yr
Statin
Repeat biomarkers
@ 30 days, 6 months
Proximal 6-8
cm of each
coronary
artery
MSCT
Substudy
F/U: 1 mo, 6 mo,
1 yr, 2 yr,
±3-5 yrs
N=50-100
Repeat imaging
in pts with events
PROSPECT: Methodology
Virtual histology lesion classification
Lesions are classified into 5 main types
1. Fibrotic
2. Fibrocalcific
3. Pathological intimal thickening (PIT)
4. Thick cap fibroatheroma (ThCFA)
5. VH-thin cap fibroatheroma (VH-TCFA)
(presumed high risk)
PROSPECT 82910-012: 52 yo♂
2/13/06: NSTEMI, PCI of MLAD
2/6/07 (51 weeks later): NSTEMI attributed to LCX
Index 2/13/06
Event 2/6/07
QCA PLCX DS 28.6%
QCA PLCX DS 71.3%
PROSPECT 82910-012: Index 2/13/06
1
*
Baseline PLCX
QCA: RVD 2.82 mm,
DS 28.6%, length 6.8 mm
IVUS: MLA 5.3 mm2
VH: ThCFA
Lesion
prox
*OM
1. ThCFA
5.3
mm2
38
PROSPECT: MACE
All
Culprit lesion (CL) related
Non culprit lesion (NCL) related
Indeterminate
25
MACE (%)
20
20.4%
15
12.9%
10
11.6%
5
2.7%
0
0
1
2
3
Time in Years
Number at risk
ALL
697
557
506
480
CL related
697
590
543
518
NCL related
697
595
553
521
Indeterminate
697
634
604
583
PROSPECT: Multivariable Correlates
of Non Culprit Lesion Related Events
Independent predictors of lesion level
events by logistic regression analysis
Variable
OR [95% CI]
P value
PBMLA ≥70%
4.99 [2.54, 9.79]
<0.0001
VH-TCFA
3.00 [1.68, 5.37]
0.0002
MLA ≤4.0 mm2
2.77 [1.32, 5.81]
0.007
Lesion length ≥11.6 mm
1.97 [0.94, 4.16]
0.07
EEMMLA <14.3 mm2
1.30 [0.62, 2.75]
0.49
Variables entered into the model: Minimal luminal area (MLA); plaque burden at the MLA (PBMLA);
external elastic membrane at the MLA (EEMMLA) <median; lesion length ≥ median (mm); VH-TCFA.
I LIMITI DELLA CORONAROGRAFIA NELLO STUDIO DELL’ATS
CORONARICA (MALATTIA DI PARETE)
NEW
The IVUS technique can detect
angiographically ‘silent’ atheroma
Angiogram
No evidence
of disease
IVUS
Little
evidence of
disease
Atheroma
RIMODELL.POSIT.
IVUS=intravascular ultrasound
Reproduced from Circulation 2001;103:604–616, with permission from Lippincott Williams & Wilkins.