Use of OCT in Determining Dual Antiplatelet Treatment Duration Ashish Shah, Timothy Kinnaird, Richard Anderson University Hospital of Wales, Cardiff, UK

I/we have no real or apparent conflicts of interest to report. Ashish H. Shah, MD, MRCP I/we have no real or apparent conflicts of interest to report.

History 42 year – Female Presented with NSTEMI Chronic immune-thrombocytopenic purpurra (ITP) Since age of 22 years Spleenectomy 1990 DVT (2010) – after immunoglobulin therapy Treated with Mycophenolate and prednisolone Changed to rituximab Azathioprine and prednisolone (present medication) Gestational diabetes Presented with NSTEMI ECG – LAD syndrome

History and examination General and systemic examination – Normal Haemoglobin and white cell counts – Normal Platelet count - 35000/ul Required dual anti-platelet treatment Haematologist consult IV immunoglobulin – to increase platelet count 48 hours later – platelet count - 85000/ul Underwent coronary angiography

Coronary angiogram

LCx

RCA

PCI

PCI

PCI

PCI

PCI to LAD Stented with 3.5 x 23 mm Genous stent Antibody to CD-34 coated stent Short duration of dual anti-platelet 1 week / 1 month Low platelet count Significant bruise Discharged with Aspirin + clopidogrel The coronary stent inserted in this patient was a Genous R-stentTM (OrbusNeich, Fort Lauderdale, FL, USA). This is a new bio-engineered stainless steel coronary artery stent coated with a biocompatible matrix covered with antibodies specific to CD34, a surface antigen present on circulating endothelial progenitor cells (EPCs). After stent insertion, these antibodies capture endogenous EPC from the circulation and these EPC mature into endothelial cells. This process causes endothelial healing to occur in a rapid and controlled manner, thus facilitating and accelerating the natural healing process and minimizing the time at which the stent surface is exposed to the risk of thrombosis. As a result of this rapid endothelialization, the manufacturers recommend only 4 weeks of dual antiplatelet therapy. However, these stents have been implanted with as little as 7 days clopidogrel treatment and varies at the discretion of the cardiologist. This obviously has potential advantages over traditional bare metal stents in patients who require urgent non-cardiac surgery with regard to the period when antiplatelet treatment is required. We believe this case adds to the current knowledge of coronary artery stents and highlights the importance of liaising with the cardiologists. These stents may be most useful in those patients who require urgent non-cardiac surgery. The initial trials of these stents56 seem promising but as ever we await the evaluation of long-term outcome studies.

Re-admission Advised to stop clopidogrel after 1 week 3 days after stopping clopidogrel Further episode of chest pain Anterior STEMI

Presented 10 days later with ant STEMI 14

Thrombus - aspiration 15

PCI to LAD (in-stent thrombosis) 16

PCI to LAD for IST 17

PCI to LAD for IST 18

PCI to LAD 19

Post PCI 20

PPCI for stent thrombosis PCI with two 3.5 x 13 mm Genous stents Aspirin + Ticagrelor ? Duration of DAPT 21

PCI (21st June) – OCT (30th July) 22

OCT

Summary & conclusion What platelet count is acceptable - DAPT? Dual anti-platelet treatment in ITP What anti-platelet to use ? Platelet stimulant / anti-platelets Increased risk of stent thrombosis Special cohort – requiring multi-disciplinary management OCT – helpful in deciding DAPT duration 24

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