1. RESEARCH, REDUCE III, X-AMINE ST, COOL-MI Azfar Zaman Freeman Hospital, Newcastle

2. 1. Rapamycin Eluting Stent Evaluated At Rotterdam Cardiology Hospital Rationale Sirolimus eluting stents reduce restenosis and reintervention Sirolimus eluting stents reduce restenosis and reintervention Increased risk of early and late stent thrombosis Increased risk of early and late stent thrombosis Are SES safe and effective in a thrombogenic environment post STEMI? Are SES safe and effective in a thrombogenic environment post STEMI? RESEARCH

3. Recruitment 96 patients with STEMI enrolled as part of registry of SES implantation in Rotterdam 96 patients with STEMI enrolled as part of registry of SES implantation in Rotterdam ACT>300 (200-250 with IIb/IIIa) ACT>300 (200-250 with IIb/IIIa) Clopidogrel between 3-6 months Clopidogrel between 3-6 months RESEARCH

4. Results MACE ( death, nonfatal MI, reintervention ) + 6 m angiogram MACE ( death, nonfatal MI, reintervention ) + 6 m angiogram mean age 57y, IIb/IIIa in 46.9% mean age 57y, IIb/IIIa in 46.9% ref. diameter 2.73 ± 0.59, length 16.9 ± 9.95 mm ref. diameter 2.73 ± 0.59, length 16.9 ± 9.95 mm No early or late stent thromboses No early or late stent thromboses No reinterventions and no restenosis No reinterventions and no restenosis RESEARCH

5. Relevance Single centre registry data but unrestricted Single centre registry data but unrestricted NICE (DES >15 mm / 15 mm /<3 mm ) “except if MI in preceding 24h or evidence of thrombus” Supporting evidence for safe use (of sirolimus) in MI – “need larger studies” Supporting evidence for safe use (of sirolimus) in MI – “need larger studies” RESEARCH

6. 2. Restenosis Reduction by Cutting Balloon Evaluation III Rationale Failure of CB to reduce angiographic or clinical outcomes in ISR (versus standard balloon) Failure of CB to reduce angiographic or clinical outcomes in ISR (versus standard balloon) Can predilation with CB versus standard balloon before bare metal stent deployment reduce restenosis ? Can predilation with CB versus standard balloon before bare metal stent deployment reduce restenosis ? REDUCE III

7. Recruitment Randomised, multicentre (Japan) Randomised, multicentre (Japan) 521 patients 521 patients Mean age 65 years Mean age 65 years REDUCE III

8. Results End-pointCBN=228POBAN=224p lesion length(mm) 14.4±5.4 15.2±5.3 ns vessel diameter 3.33±0.38 3.27±0.4ns MACE12.3%16.1%ns Restenosis at 6m 11.8%19.1%0.03

9. Relevance A role for cutting balloon……at last? A role for cutting balloon……at last? DES for “NICE” lesions, CB plus BMS for others DES for “NICE” lesions, CB plus BMS for others Promising…….2 years too late? Promising…….2 years too late? REDUCE III

10. 3. X-Sizer in AMI patients for Negligible Embolization and optimal ST resolution Rationale TIMI-3 flow after PCI for AMI is criteria for success TIMI-3 flow after PCI for AMI is criteria for success But may not have myocardial perfusion due to distal embolisation But may not have myocardial perfusion due to distal embolisation Thrombectomy can improve myocardial perfusion as assessed by ST resolution Thrombectomy can improve myocardial perfusion as assessed by ST resolution X-AMINE ST

11. Recruitment AMI  12 hours in patients NOT receiving AMI  12 hours in patients NOT receivingthrombolysis 56% received IIb/IIIa 56% received IIb/IIIa 200 patients, 6 month follow-up 200 patients, 6 month follow-up X-AMINE ST

12. Results No difference in clinical outcomes No difference in clinical outcomes EndpointCX-Sip ST-res Mean Med>50% 6.8 mm 4.953.1%8.5mm7.567.4%ns0.0360.052 Slow, no flow 164.10.012 TIMI 3 Emboli89%10%95.7%2.1%ns0.006 Time(min) 45±25 55±28 0.003 X-AMINE ST

13. Relevance Complementary therapy to antithrombotics in AMI Complementary therapy to antithrombotics in AMI Await longer term clinical outcomes data Await longer term clinical outcomes data Useful in patients in whom antithrombotics should be kept to a minimum Useful in patients in whom antithrombotics should be kept to a minimum X-AMINE ST

14. 4. Cooling as an Adjunctive Therapy to Percutaneous Intervention in Patients with Acute Myocardial Infarction Rationale In animal MI models, hypothermia reduces metabolic demand and infarct size In animal MI models, hypothermia reduces metabolic demand and infarct size mild hypothermia inhibits platelet aggregation mild hypothermia inhibits platelet aggregation test safety and efficacy of cooling (<35ºc) as adjunctive therapy to primary PCI for AMI compared to PCI alone test safety and efficacy of cooling (<35ºc) as adjunctive therapy to primary PCI for AMI compared to PCI alone COOL-MI

15. Recruitment 357 patients enrolled: prospective, randomised 357 patients enrolled: prospective, randomised Acute MI < 6 h Acute MI < 6 h End-point - infarct size at 30 days End-point - infarct size at 30 days COOL-MI

16. Results No difference in end-point of infarct size No difference in end-point of infarct size Incidence of shock higher in cooling arm Incidence of shock higher in cooling arm Benefit in anterior MI cooled to <35ºc Benefit in anterior MI cooled to <35ºc COOL-MI

17. Relevance Nil (at present) Nil (at present) More effective rapid cooling needed More effective rapid cooling needed ( difficult in humans because of large thermal mass ) ( difficult in humans because of large thermal mass ) Further work in anterior MI Further work in anterior MI Beta blockers? Beta blockers? COOL-MI

18. Thank you