急诊PCI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PCI的若干问题Randomization50 GenousTM50 CrCo6-month clinical, angio 371:1915-20; Svilaas T, et al. N Engl J 2008;358:557-676F Export aspiration catheterintention-to-treat trial Routine utilization of TAn=535 for TAn=536 for conventional PPCIFollow-up for 1 yrmortalityA meta-analysis of adjunctive thrombectomy and embolic protection devices in STEMI1996-2008 30 randomized trials n= 6415 patients 12h native vessel STEMI Endpoints:All cause mortalityMACEStrokeBavry AA. et al., European Heart J. 2008;29:298930016 month5 month4 month13 trials n=30265 trials n=93412 trials n=244212 h STEMI TIMI 0-1 n=49 successful aspiration with visible material DIVER CE and ZEEKYAN hongbing et al.0.590.52 0.480.50.520.540.560.580.6146257.9050100150200250300Presence of plaque material Presence of thrombus onlyPresence of plaque material Presence of thrombus onlyLVEF 16hr post-proceduralP0.02P0.02Peak CK-MB post-proceduraln=28n=28n=21n=28 n=21Plaque materialRemoving plaque materials from the culprit lesion is beneficialShould TA be routinely performed in TIMI 2-3 patients? Needs trialsAre there any differences 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. large smallmoderateFrequency of dual-wiresClinical impacts of Diver CE vs ZEEKYAN hongbing et al. Chin Med J 2009;122(6):648-654AMI直接PCI支架血栓的预测因素： HORIZONS-AMI试验 No limitations for drug-eluting stents in STEMI patients1yr End points DES Taxus, n=2257 (%) BMS Express, n=749 (%) Hazard ratio (95% CI) Ischemic target lesion revascularization 4.5 7.5 0.59 (0.430.83) 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 Scientific 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, lesion 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 in 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 Trial 6 month angio & IVUS dataGenous Genous Cr-Co Cr-Co P valueP valueANGIO DATAANGIO DATA N=44N=44 N=47 N=47Late lumen loss (mm) 0.890.59 0.790.47 NS Late lumen loss (mm) 0.890.59 0.790.47 NSRestenosis (50%) 20 13 NS Restenosis (50%) 20 13 NS(QCA: Pie Medical Im)(QCA: Pie Medical Im)IVUS N=41 N=42mean in-stent NIH mean in-stent NIH (mm(mm3 3) ) 49.749.7 4848 40.022.8 NS 40.022.8 NS(Volcano, pull back 0.5%mm/s)(Volcano, pull back 0.5%mm/s)(QIVA Pie Medical Im) (QIVA Pie Medical Im) NIH: Neointimal hyperplasia inside the stent