William Wijns MD PhD Thomas Cuisset MD DES Thrombosis, Restenosis & DAPT Duration  DES Thrombosis No Longer an Issue with Second Generation DES William Wijns MD PhD NUI Galway, Ireland Thomas Cuisset MD Marseille, France

William Wijns, MD PhD Relations of Interest Disclosures   Relations of Interest Disclosures Institutional Research Grants: MICell Technologies, MicroPort, St Jude- Abbott, Terumo Advisory Board & honoraria: MicroPort Shareholder & non executive Board member:  Argonauts, Genae

DAPT = Gold standard after ACS and DES 1 m 3 m 6 m 12 m 30 m LONG SHORT Thrombotic risk Bleeding Risk Stent thrombosis Recurrent ACS Bleeding events

Improvement of DES technology Thinner strut Biodegradable polymer Abluminal polymer Drug and polymer release → Lower risk of ST ? → Shorter DAPT possible ? Stefanini, Taniwaki, Windecker. Heart 2013

“Short DAPT” as effective with less bleedings % ACS Ischemic Bleeding DES LATE, NEJM 2010 2117 60% 12 Mo = >12Mo No difference EXCELLENT, JACC 2012 1443 50% 6 Mo = 12Mo No Difference PRODIGY, Circulation 2012 2013 75% 6 Mo = 24 Mo More bleeding RESET, JACC 2012 55% 3 Mo = 12 Mo OPTIMIZE, JAMA 2013 3119 30% ARCTIC, Lancet 2014 1259 25% More Bleeding SECURITY, JACC 2014 1399 40% 6 Mo = 12 Mo ISAR SAFE, EHJ 2015 4005 ITALIC, JACC 2014 2031 OPTIDUAL, JACC 2015 1385 35% 12 Mo = 48 Mo No DIfference “Short DAPT” as effective with less bleedings

Short vs Long DAPT: Choice? Young patient Low Bleeding risk Multivessel disease Complex PCI Prior Stent thrombosis STEMI Diabetic First generation DES BRS Elderly patient High Bleeding risk Patient with OAC ‘Simple’ PCI, single VD Stable CAD Non Diabetic New generation DES Short DAPT Long DAPT

Prior Stent thrombosis Short vs Long DAPT: Choice with the patient Young patient Low Bleeding risk Multivessel disease Complex PCI Prior Stent thrombosis STEMI Diabetic First generation DES BRS Elderly patient High Bleeding risk Patient with OAC ‘Simple’ PCI, single VD Stable CAD Non Diabetic New generation DES Short DAPT Long DAPT

Short vs Long DAPT: Choice with the PCI Young patient Low Bleeding risk Multivessel disease Complex PCI Prior Stent thrombosis STEMI Diabetic First generation DES BRS Elderly patient High Bleeding risk Patient with OAC ‘Simple’ PCI, single VD Stable CAD Non Diabetic New generation DES Short DAPT Long DAPT

the assessment of drug-eluting stent-associated coronary inflammation Optical coherence tomography-near-infrared fluorescence (OCT-NIRF) imaging for the assessment of drug-eluting stent-associated coronary inflammation Pigs in vivo. Optical coherence tomography-near-infrared fluorescence (OCT-NIRF) imaging for the assessment of drug-eluting stent-associated coronary inflammation. (A) OCT-NIRF cross-section showing strong NIRF signals along stent struts (arrowheads). (B and C) In vivo NIRF (colour table: red hot) overlaid on en face OCT (grey) showing augmented inflammatory activity at 14-day-drug-eluting stent compared with baseline. (D and E) Three-dimensional OCT-NIRF in vivo rendering image co-localized with ex vivo confocal laser scanning microscopy image of drug-eluting stent-implanted artery (indocyanine green in red, autofluorescence in cyan). (F) OCT-NIRF matched NIRF-enhanced areas on confocal laser scanning microscopy (indocyanine green in red, and autofluorescence in green) co-localize well with macrophage-positive peri-strut tissue. (G) Comparison of NIRF activity between Day 1 vs. Day 14. (H) Correlation of NIRF signals between in vivo NIRF map vs. ex vivo fluorescence reflectance imaging (Pearson's r = 0.88, P < 0.0001). Equally windowed. Scale bars, 1 mm (A–E), 50 µm (F). Sunwon Kim et al. Eur Heart J 2016;eurheartj.ehv726 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.

Impact of PCI Complexity on long-term DAPT benefit Factors of Complex PCI 3 Vessel PCI Bifurcation w/ 2 DES ≥ 3 DES Total DES lenth > 60 mm CTO → 17.5% of patients 9577 patients from DAPT duration studies > 12 Mo vs 3-6 Mo DAPT Giustino et al, JACC 2016

PEGASUS study -1.2% +1.2% 60 mg + 1.5% 90 mg Bonaca et al, NEJM 2015

Choice of DAPT duration: Rule and exceptions ! After DES Improvement of DES technology Evidence that shorter DAPT is safe in low-risk patients with new DES 6 Mo as rule, shorter in high bleeding risk patients (1-3) Longer in very selected patients After ACS 12 Mo as rule, shorter in high bleeding risk patients (1-3-6) Evidence that high-risk ACS pts benefit from longer DAPT (CHARISMA post-MI, DAPT post-MI, PEGASUS)

DAPT duration DAPT indication  Prevention of recurrent events For the patient ? Optimal Duration For DES ? Minimal Duration ?  Prevention of recurrent events  Prevention of stent thrombosis