急诊PCI的若干问题课件.ppt

1、急诊急诊PCI的若干问题的若干问题 Endothelial progenitor cell(EPC)capturing stents High dose GP IIb/IIIa inhibitors pre-hospitalization Manual thrombus aspiration(TA)during PPCI Predictors of stent thrombosis after PPCI急诊急诊PCI的若干问题的若干问题Randomization50 GenousTM50 CrCo6-month clinical,angio&IVUS FUGENIUS-STEMI Trial2

2、007.8-9,Single center prospectiveASA 100mg/day+clopidogrel 75mg/day 30 daysGPIIb/IIIa inhibitors and thromboaspiration at the discretion of the physicianPresented by Dr.Pavel Cervinka at ACC.09/i2,Orlando,FLGENIUS-STEMI Trial6-month clinical outcomeMACE CV Deaths MI TLR STP=0.03P=NSP=0.04P=NSP=NSGen

3、ousTMCrCo2410Presented by Dr.Pavel Cervinka at ACC.09/i2,Orlando,FL GENIUS-STEMI TrialConclusionsThe use of EPC capture stents in the setting of STEMI is feasible&safe.Rate of MACE at 6-month FU was significantly higher in GenousTM group than CrCo stents.Warrisome is the rate of late stent thrombosi

4、s in EPCs capture stent group.Larger randomized trials are mandatory.Presented by Dr.Pavel Cervinka at ACC.09/i2,Orlando,FL直接直接PCI患者院前与导管室应用患者院前与导管室应用大剂量替罗非班的比较大剂量替罗非班的比较ON-TIME-2研究研究AGIR-2研究研究Prospective,multicentre,placebo-controlled,randomisedSTEMI 30min-24hrs 5000 UFH,500mg ASA,600 mg Clopidogre

5、lAngiogramTirofiban*PlaceboTransportationPCI centreAngiogramTirofibanprovisionalTirofiban contdON-TIME-2 one yr follow-up n=9842006.6-2007.11PPCI*Bolus:25 g/kg&0.15 g/kg/min infusionFollow-upON-TIME-2Christian W.Hamm et al.Conclusions-Strong trend to reduced mortality continues over 1 year follow-up

6、-In patients undergoing primary PCI mortality is significantly lower.-Highest efficacy in elderly(65 yrs),in Killip class 2 and in early presenters.ON-TIME-2Christian W.Hamm et al.MICUPatientcallSTEMI undergoing primary PCISTEMI 20min-12h600 mg clopidogrel250 mg aspirinUFH 60 U/kgTirofiban25g/kg bol

7、us,0.15ug/kg ivgttAngiographyAngiographyPre-hospitalMICUtransportationCath labRandomize Open LabelMedical DispatcherTirofiban25g/kg bolus,0.15ug/kg ivgttAGIR2(n=156)(n=156)PPCIEric Bonnefoy et al.3.21.31.90.65.53.70.61.20123456DeathSevere BleedingAcute stentthrombosisStrokeCath lab tirofibanPre-Hosp

8、ital tirofiban%p=NSp=NSp=NSp=NSIn-hospital eventsP=NSOn admission to Cath labP=NSP=NSInitial TIMI grade 2-3ST segment resolution 70%39.744.298.1978.715.255.452.60 02020404060608080100100120120%Final TIMI grade 2-3P=NSCath lab tirofibanPre-hospital tirofibanSurrogates of reperfusionOne hr after PCIAG

9、IR2Results and ConclusionThe results do not support the necessity to initiate tirofiban administration in pre-hospital settingsEric Bonnefoy et al.急诊急诊PCI血栓抽吸装置的应用血栓抽吸装置的应用Manual thrombus aspiration(TA)during PPCIErythrocyte-rich thrombiPlatelet/fibrin-rich thrombiCombined thrombiEdematous component

10、sAtherosclerotic components45231454FreshFormalin fixedFormalin fixedHEHEYAN hongbing et al.TAPAS and 1-year follow-up4.77.63.66.72.24.30%1%2%3%4%5%6%7%8%All causemortalityCardiacdeathReinfarctionTAPAS 1-year follow-upP=0.04P=0.02P=0.05Asp ConAsp ConAspConpatient0%20%40%60%80%100%45.732.237.141.417.1

11、26.3AspConMBG 0-1MBG 2MBG 3Myocardial Blush GradeP0.00156.630.812.644.237.917.90%20%40%60%80%100%STR30%STR 30-70%MBG70%Asp ConResolution of ST-segment ElevationP0.001Vlaar P,et al.Lancet 2008;371:1915-20;Svilaas T,et al.N Engl J 2008;358:557-676F Export aspiration catheterintention-to-treat trial Ro

12、utine utilization of TAn=535 for TAn=536 for conventional PPCIFollow-up for 1 yrmortalityA meta-analysis of adjunctive thrombectomy and embolic protection devices in STEMI1996-200830 randomized trialsn=6415 patients 12h native vessel STEMIEndpoints:All cause mortality MACE StrokeBavry AA.et al.,Euro

13、pean Heart J.2008;29:298930016 month5 month4 month13 trialsn=30265 trialsn=93412 trialsn=244212 h STEMITIMI 0-1n=49 successful aspiration with visible materialDIVER CE and ZEEKYAN hongbing et al.0.590.520.480.50.520.540.560.580.6146257.9050100150200250300Presence of plaque materialPresence of thromb

14、us onlyPresence of plaque materialPresence of thrombus onlyLVEF 16hr post-proceduralP0.02P0.02Peak CK-MB post-proceduraln=28n=28n=21n=28n=21Plaque materialRemoving plaque materials from the culprit lesion is beneficialShould TA be routinely performed in TIMI 2-3 patients?Needs trialsAre there any di

15、fferences of devices operability and clinical impacts among different type aspiration catheters?YAN hongbing et al.Chin Med J 2009;122(6):648-654Size distribution of thrombiP=0.02 for small,P=0.09 for moderate and P=0.03 for large thrombi.largesmallmoderateFrequency of dual-wiresClinical impacts of

16、Diver CE vs ZEEKYAN hongbing et al.Chin Med J 2009;122(6):648-654AMI直接直接PCI支架血栓的预测因素：支架血栓的预测因素：HORIZONS-AMI试验试验 No limitations for drug-eluting stents in STEMI patients1yr End points DESTaxus,n=2257(%)BMSExpress,n=749(%)Hazard ratio(95%CI)Ischemic target lesion revascularization 4.5 7.5 0.59(0.430.8

17、3)Safety MACE 8.1 8.0 1.02(0.761.36)All-cause mortality 3.5 3.5 0.99(0.641.55)MI 3.7 4.5 0.81(0.543.22)Stroke 1.0 0.7 1.52(0.584.00)Stent thrombosis 3.1 3.4 0.92(0.581.45)Binary restenosis,per lesion,at 13 mo 10.0 22.9 0.44(0.330.57)TCT 2008:Transcatheter Cardiovascular Therapeutics 20th Annual Scie

18、ntific Symposium October 12-17,2008,Washington,DCEnd pointsIndependent Predictors of ST(Cox Model)Acute STSubacute STLate STConclusions Acute,subacute&late ST appear to be related to different factors the most important predictors of acute&subacute ST events:Pharmacological therapy,vessel flow,lesio

19、n characteristics&number&length of stents the most important predictors of late ST events:Patient related factors including cigarette smoking&prior MI The type of stent implanted(DES vs.BMS)was not related to ST during any time interval up to 1-year ST within 1-year occurred with similar frequency i

20、n patients treated with UFH+GPI&bivalirudin alone However,acute ST was more common with bivalirudin,especially within the 1st 5 hours,whereas ST tended to be less common with bivalirudin than with UFH+GPI between 24 hours&1-yearThank you!GENIUS-STEMI Trial6 month angio&IVUS data IVUS N=41 N=42NIH:Neointimal hyperplasia inside the stent