GaneshRaveendran,M.D.,M.S.

Director;SectionofInterventionalCardiology

&CardiovascularFellowshipProgram

UniversityofMinnesotaMedicalSchool

AdvancesinInterventionalCardiology

•  Thefirstballoonangioplastywas

performedbyAndreasGrüntzigin1977

•  Atfirst,PTCAwaslimitedtopatients

withadiscrete,proximal,concentric

andnon‐calcificlesioninasinglemajor

coronaryarterywithnoinvolvementof

majorsidebranchesorangulations

AndreasGrüntzig

AnrdeasGrüntzig,1939‐1985

LandmarkTrialsEarlyBMSStudies

STRESSn=410 BENESTENTn=520

PSerruysetal.,NEnglJMed1994

mm P<.001

DLFishmanetal.,NEnglJMed1994

P<.001 p=0.01 mm P<.001 P<.001 p=0.09

PTCAstent

In-stent Restenosis

SIRIUS:AngiographicandClinicalEndpoints

Sirolimus Stent

Bare Stent

91% reduction

p<0.001

Sirolimus Stent

Bare Stent

MACE

p<0.001

TAXUSIVTrialTarget vessel

revascularization p<0.0001

Similar Clinical Events

Increased Late Loss

Angiographic & clinical outcome

TVF=cardiacdeath,MI,orischemia‐drivenTVR

TVF(%)

Months

10.7%

15.4%

2‐yearHR0.68[0.48,0.98]

P=0.04

Δ4.7%10.8%

8.3%

1‐yearHR0.73[0.48,1.10]

P=0.13

Δ2.5%

0%

5%

10%

15%

20%

0 3 6 9 12 15 18 21 24

XIENCEVTAXUS

FullyBiodegradableStentPlatforms

1996

VanderGiessenCirculation

Animalstudiespolymericscaffoldsrevealingexcessive

inflammatoryreactions

IgakiTamaiFirstfullybiodegradablenondrugelutingscaffold

N=15

TamaiCirculation

Bioresorbablevascularscaffold

firstbioabsorbabledrugelutingscaffold

N=31

OrmistonLancet

AMS‐1firstbioabsorbablemetallicnondrug‐elutingscaffold

N=64

ErbelLancet

2000 2007 2008

JabaraPCR2009

2009

REVAPolycarbonatestent,radiopaque,nondrug‐

elutingscaffoldN=31

IDEALBDSPolyanhidride

esterandsalicylicacid,drug‐elutingscaffold

N=11

AbizaidTCT2009

DREAMSfirstdrug‐elutingbioabsorbablemetallicscaffold

N=22

HaudePCR2011

2011

ThePathophysiologyofAMI

p=0.0002 p=0.0003

TrendsinAcuteReperfusion

BenefitsofDTBreduction?

PCIWithoutSurgeryBackupMayoExperience

PCIWithoutSurgeryBackupMayoExperience

FrequencyofCardiogenicShock

1Babaev A et al : JAMA 2005; 294:444-454 2Goldberg RJ NEJM 1991; 325:1117 3 Holmes DR JACC 1995 26:668

Total Shock

Clinical Event

Shock at Presentation

Worcester Heart Attack Study2 : 1975-88 7.5%

Gusto-13: 1995 7.2%

NRMI Registry1: N=293,633 NRMI STEMI Registry N=25,311

Jan 1995-May 2004

STEMI or new LBBB

775 US Hospitals with on-site PCI

CS developed in 25,311 (8.6%) pts,

CS present on admission in 2.9%

History

Impella

TandemHeart

30 Day Mortality

Cardiohelp

IPTCA

Theevolution….

Do#erDCA,ROTAand

adjunc3vedevices PSstent IGenera(onDES

NewBMSstents

1965 2002‐…

whatnext?

IIGenera(onDES

TheEvolu3onofInterven3onalCardiology……

1977 ’90s‘80s

CalcificAorticStenosis

NaturalHistoryofAorticStenosis

SevereSymptomaticAS:30%Untreated

WhoLikesSurgery?

EarlyCatheter‐basedAVDesigns

TheDavisvalve(1965)

TheAndersenvalve(1992)

PercutaneousTranscatheterImplantationofanAorticValveProsthesisforCalcificAorticStenosisFirstHumanCaseDescription

AlainCribier,MD;HeleneEltchaninoff,MD;AssafBash,PhD;NicolasBorenstein,MD;ChristopheTron,MD;FabriceBauer,MD;GenevieveDerumeaux,MD;FredericAnselme,MD;FrançoisLaborde,MD;MartinB.Leon,MD

Adopted from TCT presentation: Dr. Leon

Source:BIBAMedical,UK‐basedproviderofmarketanalysisforthemedicaldeviceindustry

2010 2011

MarketShareAcrossEUCountries

Germany

FranceItaly

UK

Spain

Netherlands

Switzerland

Others

Germany

France

Italy

UK

Spain

Netherlands

Switzerland

Austria

Others

0%

20%

40%

60%

80%

100%

0 6 12 18 24

PrimaryEndpoint:AllCauseMortality

Allcausemortality

HR[95%CI]=0.51[0.38,0.68]

p(logrank)<0.001

∆at1yr=20.0%NNT=5.0pts

50.7%

30.7%

179179

TAVRStdTxNumbersatRisk

138121

12485

10356

6024

Months

TAVR

StdTx

0

0.1

0.2

0.3

0.4

0.5

0 6 12 18 24

TAVR AVR

Months

348 298 260 147 67

351 252 236 139 65

No.atRisk

TAVR

AVR

26.8

24.2

HR[95%CI]=0.93[0.71,1.22]P(logrank)=

0.62

CurrentTAVREligibilityAccordingToOperativeRisk

Reasonable

Adapted from S. Kodali

Low or Moderate High Inoperable

BalloonValvuloplasty

ValveImplantation

PostValveImplantAssessment

ImplantationofValve