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David Antoniucci

FIC – Congresso Tosco-Umbro Montecatini, Novembre 2007. PTCA primaria del vaso colpevole: quando estendere la rivascolarizzazione nel multivaso sulla base angiografica. David Antoniucci. CS – Predictors of Mortality. All pts ( n = 280)

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David Antoniucci

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  1. FIC – Congresso Tosco-Umbro Montecatini, Novembre2007 PTCA primaria del vaso colpevole: quando estendere la rivascolarizzazione nel multivaso sulla base angiografica. David Antoniucci

  2. CS – Predictors of Mortality All pts ( n = 280) Age HR 1.064 ( 95% CI 1.043-1.086) P < 0.0001 PCI Failure HR 4.727 (95% CI 2.292-9.746) P < 0.0001 Non-Anterior AMI HR 0.562 (95% CI 0.343-0.923) P = O.002 Multivessel Disease 1.475 (1.124-1.936) P = 0.005 Age > 75 yrs (Age,HR 1.07 and PCI failure, HR 4.01) Antoniucci, Am Heart J 2006

  3. I.Z., f, 99 yrs • Anterior AMI complicated by cardiogenic shock. • Time symptom onset to treatment 2.5 hrs. • LM, LAD and Circ diffuse disease. • Reopro plus IABP. Norepinephrine infusion. • PTCA and spot stenting IVA  TIMI 3; stenting LM-LCX, and T stenting LAD ostium. • 30 min. ST-segment resolution = 50%. Post-PCI EF = 20%. • Peak CPK = 2777 U/l at 6° hr.

  4. I.Z., f, 99 yrs Multivessel PCI

  5. I.Z., f, 99 yrs

  6. I.Z., f, 99 yrs

  7. MVD and Post-PCI No-Reflow

  8. The Minimal Approach

  9. LM Occlusion – Thrombectomy Approach

  10. AMI and Multivessel Disease Incidence 40% to 65%. CTO > 10%. Increased morbidity and mortality compared to SVD.

  11. Multivessel PCI in AMI Corpus RA, Am Heart J 2004 MVD = n =506 (>70%diameter stenosis) One-Year Outcome PCI IRA only Multivessel PCI P (n = 354) (n = 152) value Death 11% 12% 0.82 Reinfarction 2.8% 13% < 0.001 TVR 15% 25% 0.007 MACE 28% 40% 0.006 Multivessel PCI predictor of 1-year MACE: OR 1.67, 95% CI 1.10-2.54, P = 0.01

  12. AMI and Multivessel Disease CADILLAC 1-VD 2-VD 3–VD P 1,066 692 324 value (51.2%) (33.2%) (15.6%) One-year mortality3.2% 4.4% 7.8% 0.003 3-VD was the strongest predictor of 1-year death (HR 2.60, P = 0.009), death and MI (HR 1.88, P = 0.03), and MACE (HR 1.80, P < 0.001). One-year mortality was 3.5% in MVD-PCI and 5.7% in MVD-nonPCI (P=0.03) Sorajja P, Eur Heart J 2007

  13. AMI and Multivessel Disease SVD MVD MVD-CTO P n=885 n=578 n= 165 value 1-Year Mortality 8% 16% 35% < .001 Predictors of mortality: CS (OR 5.1, P < .001), PCI failure (OR 4.4, P < .001), Age > 60yrs (OR 1.7, P = 0.004), LAD-IRA (OR 1.5, P = .009), CTO (OR 3.8, P < .001) Van der Schaaf RJ, Am J Cardiol 2006

  14. AMI: Look for Vulnerable Plaques Other than the Target Lesion for the Prevention of Recurrence

  15. The Effects of an Ignored Vulnerable Plaque

  16. Complex Plaque and Vulnerable Plaque N = 253 pts with AMI, 39.5% multiple complex plaques Single Multiple P value Recurrence ACS 2.6% 19% <.001 re-PCI 12.4% 32% <.001 non-IRA re-PCI 4.6% 17% <.001 CABG 11% 35% <.001 Goldestein JA, NEJM 2000, 343: 915

  17. Three-vessel Vulnerable Plaques

  18. Multivessel Vulnerable Plaques

  19. 6-month later

  20. Expanding the Paradigm of Primary PCI Success • Try to reach an effective reperfusion both at epicardial (stenting) and microcirculatory level(abciximab, thrombectomy, filter). • Prevention of ischemia recurrence in non-IRA vessels. • Try to Reach a Stable Result(anti-inflammatory therapy, anti-platelet therapy, DES?)

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