Session 10: DCB-PCI: Current Indications II - NSTEMI and STEMI – Tuomas Rissanen

DCB in Myocardial Infarction: A Case Study

Introduction to the Case

• The speaker addresses a cancellation of the first talk and emphasizes the importance of discussing DCB (Drug-Coated Balloon) in myocardial infarction.

• Introduces a case involving a young patient with type 1 diabetes and moderately severe hemophilia, presenting with unstable angina.

Treatment Approach

• The treatment involved using a cutting balloon dilatation followed by sequential DCB, with only aspirin administered due to hematologist recommendations against P2Y12 inhibitors.

• Post-procedure, the patient was monitored for 10 minutes without any ECG changes and discharged on low-dose aspirin after two weeks.

Evidence Supporting DCB Use

• Discusses the PEPTID trial comparing pletaal DCB against stents; highlights issues with protocol changes affecting results but notes that DCB showed safety and better outcomes compared to bare metal stents.

• Refers to the BASKET-SMALL 2 trial indicating trends towards better outcomes with DCB in NSTE-MI patients, though not statistically significant.

Observational Studies and Findings

• Mentions ongoing trials like SOLUTION DENOVO which will include acute coronary syndromes excluding STEMI; no subgroup analysis available yet.

• Cites an observational study from Norwich showing similar outcomes between DCB and second-generation DES in primary PCI patients, emphasizing safety but calling for randomized trials.

Clinical Implications

• Highlights findings from observational studies regarding lower aspirin use post-DCB treatment compared to stenting, suggesting implications for bleeding risk management.

Case Example: Anterior STEMI Treatment

Patient Overview

• Describes a case of a 69-year-old male with anterior STEMI who had some flow in the culprit vessel prior to intervention.

Procedure Details

• Discusses initial small ballooning followed by NC balloon treatment at a 1:1 ratio; emphasizes importance of nitroglycerin administration during procedure for optimal results.

Outcomes Observed

• Concludes that after using DCB, there were favorable results resembling stent-like outcomes despite initial anemia concerns due to lack of lab data before PCI.

Understanding Thrombus Management in Primary PCI

Overview of Clinical Trials and Aspirin Management

• The patient presented with persistent hematuria; aspirin was stopped immediately. In cases of severe bleeding, decoral can also be paused temporarily.

• There is currently no clinically powered trial for primary PCI and DCB, but the ongoing Copernican trial in Spain aims to address this with 1,200 patients randomized after successful guidewire crossing.

Trial Design and Endpoints

• Patients will be randomized into two groups: one focused on DCB (drug-coated balloon) and the other on DS (drug-eluting stents).

• The primary endpoint of the Copernican trial is target vessel micro-infarction or ischemic TLR (target lesion revascularization) at one year, which is expected to provide significant insights.

Thrombus Considerations in Young Patients

• A case study involved a young patient with anterior myocardial infarction presenting a large thrombus in the proximal LED; thrombus aspiration was performed.

• The procedure was staged over two days to enhance thrombus penetration into the vessel wall, leading to positive outcomes observed at six months post-procedure.

Outcomes and Future Directions

• Randomized trials indicate safety for certain treatments; however, results from the solution denawward trial are awaited for further clarity.

• It appears that DCB may have a favorable application in acute coronary syndrome populations, particularly among younger patients.