reunion anual madeira 2015 imagen y análisis funcional intracoronarios
TRANSCRIPT
Imagen y análisis funcional intracoronarios
Javier Escaned MD PhD
Hospital Clínico San Carlos
Madrid
Physiology and imaging: selected areas of contributions
• Clinical practice guidelines 2014
• Better understanding of prognostic FFR information
• Symplifying assessment with imaging and physiology to increase adoption
• Potential value of physiology in STEMI
Recommendations for the clinical value of intracoronary diagnostic techniquesESC CPGs on Myocardial Revascularization
Windecker S et al. Eur Heart J 2014
Recommendations for the clinical value of intracoronary diagnostic techniquesESC CPGs on Myocardial Revascularization
Windecker S et al. Eur Heart J 2014
• … new methods and indices (including instantaneous wavefree ratio [iFR] that do not rely on the concept of maximal hyperemia have been proposed, in order to simplify studies and facilitate a wider adoption of physiological assessment.
• Further studies will need to confirm the value of these new indices in clinical decision-making
Physiology and imaging: selected areas of contributions
• Clinical practice guidelines 2014
• Better understanding of prognostic FFR information
• Symplifying assessment with imaging and physiology to increase adoption
• Potential value of physiology in STEMI
Johnson N et al. JACC. 2014;64(16):1641-1654
FFR envisaged as a continuous marker of risk
A meta-analysis of 51 FFR studies with clinical patient follow up
FFR envisaged as a continuous marker of risk
A meta-analysis of 51 FFR studies with clinical patient follow up
Johnson N et al. JACC. 2014;64(16):1641-1654
Supplementary data of FAME II study
Stratified analysis of the primary endpoint
PCI better Medical Tx better
Reclassification of treatment with FFR interrogation of all stentable vessels (RIPCORD)
Curzen N et al . Circ Cardiovasc Interv. 2014
200 stable patients undergoing coronary angiography.
Reclassification of treatment with FFR interrogation of all stentable vessels (RIPCORD)
Curzen N et al . Circ Cardiovasc Interv. 2014
Routine pressure wire assessment during diagnostic angiography in stable patients leads to a change in treatment strategy in 26% of the cases.
Reclassification of treatment with FFR interrogation of all stentable vessels (RIPCORD)
Curzen N et al . Circ Cardiovasc Interv. 2014
Physiology and imaging: selected areas of contributions
• Clinical practice guidelines 2014
• Better understanding of prognostic FFR information
• Symplifying assessment with imaging and physiology to increase adoption
• Potential value of physiology in STEMI and ACS
Diagnosis efficiency of Pd/Pa(An ADVISE II post hoc analysis)
Echavarría-Pinto M J et al JACC C Intvn 2015
Can contrast injection better approximate FFR compared to pure resting physiology? (CONTRAST)
Johnson N et al EuroPCR 2015
750 subjects (prospective) with 1 lesion/patient enrolled in 15 centres
Can contrast injection better approximate FFR compared to pure resting physiology? (CONTRAST)
contrast = 85.5% accuracyiFR = 79.6% accuracyPd/Pa = 78.4% accuracy superior accuracy (p<0.001)
Optimal binary cutoff for contrast Pd/Pa ≤0.83
Johnson N et al EuroPCR 2015
Co-registration of angiography with intracoronary imaging
Cases performed at Hospital Clinico San Carlos / Madrid
Aim of the study: To investigate if co-registration had the potential for improving positioning of stents compared to operator mind mapping of OCT to angiography during PCI.
n=22
Co-registration of OCT and X-ray angiography in PCI: the DOCTOR study
Hebsgaard et al. Int J Cardiol 2015; 182: 272–278
Co-registration of OCT and X-ray angiography in PCI: the DOCTOR study
Hebsgaard et al. Int J Cardiol 2015; 182: 272–278
Without access to the computer-based co-registration, segments of the target lesion indicated on OCT were left uncovered by stent in 14 patients (70%)
FFR 0.58
Intracoronary FFR mapping during i.v. adenosine
Case performed at Hospital Clinico San Carlos / Madrid
Adenosine-free iFR pressure mapping
DES 2.25 x 15
Pre
Post
Case performed at Hospital Clinico San Carlos / Madrid
Nijjer S et al. JACC Cardiol Intv. 2014
iFR coronary mapping and virtual PCI simulations
PrePCI
PostPCI
CABG +
follow up with MSCT
Influence of pressure pullback derived patterns of diffuse disease on IMA-CABG outcome
Shiono Y et al EuroPCR 2015
Influence of pressure pullback derived patterns of diffuse disease on IMA-CABG outcome
Follow-up with MSCT
IMA failure: 9% 31%p=0.020
Shiono Y et al EuroPCR 2015
Physiology and imaging: selected areas of contributions
• Clinical practice guidelines 2014
• Better understanding of prognostic FFR information
• Symplifying assessment with imaging and physiology to increase adoption
• Potential value of physiology and imaging in STEMI
STEMI and multivessel disease: what to do and when?
PRAMI / Wald et al. NEJM 2013 CVLPRIT / Gershlick et al. ESC 2014
Pivotal studies supporting the value of complete revascularization in patients with STEMI and MVD (PRAMI and CVLPRIT) used angiographic guidance alone.
MAC
E (p
rimar
y en
dpoi
nt)
DANAMI 3-PRIMULTI: staged FFR-guided management of non-culprit stenoses
Complete FFR guided revascularisation of MVD STEMI patients, staged within the index admission, reduced the primary endpoint. This reduction was driven by repeat revascularisations and not by hard endpoints
Engstrøm T et al ACC 2015
N=313
N=314
Modification of thrombus burden by aspiration in the TOTAL trial assessed with OCT
Bhindi et al Eur Heart J 2015
Modification of thrombus burden by aspiration in the TOTAL trial assessed with OCT
• No impact of thrombectomy vs. PCI-alone on pre-stent thrombus burden.
• Both interventions were associated with a low level of culprit lesion thrombus in the majority of patients, and with similar thrombus burden after stenting.
Bhindi et al Eur Heart J 2015
End or the paradigm of thrombus embolization as
major determinant of outcome (TOTAL trial)
Growing evidence of the prognostic role of intramyocardial
haemorrage in STEMI
Improving outcomes in STEMI
QR
P
s
aoP
dR
d>100μmR
capR
d<100μm
Rmicro
P zf
Neurohumoral
Endothelial (flow)Metabolic
FFR, iFR, d-FFR,HSR IHDVPS, HMR, IMR
CFR (thermo), CFVR (Doppler)
IHDVPS-Pzf
Exploring the culprit vessel of STEMI
WIA
QR
P
s
aoP
dR
d>100μmR
capR
d<100μm
Rmicro
P zf
Neurohumoral
Endothelial (flow)Metabolic
IHDVPS-Pzf
WIAMVO pattern in MRI after STEMI
Exploring the culprit vessel of STEMI
PREDICT-MVI: Anticipating the development of microvascular injury after primary PCI in STEMI
In PREDICT-MVI Doppler-pressure interrogation was performed in 60 pts immediately after PCI to investigate whether MVI can be anticipated in the cath lab
Teunissen PF et al Circulation C Intv 2015
PREDICT-MVI: Anticipating the development of microvascular injury after primary PCI in STEMI
Post-analysis with pressure-velocity loops allowed calculation of resistance, conductance and zero flow pressure (compression of the microcirculation)
Teunissen PF et al Circulation C Intv 2015
PREDICT-MVI: Anticipating the development of microvascular injury after primary PCI in STEMI
MRI and PET were performed to assess the predictive value of indices that could be measured in the cath lab during PPCI
Teunissen PF et al Circulation C Intv 2015
PREDICT-MVI: role of microcirculatory compression (zero flow pressure, Pzf)
Teunissen PF et al Circulation C Intv 2015
From an strictly personal point if view:
which was the publication in 2015 that hasinfluenced me most?
50 chapters and more than 30 clinical cases
Available at the PCR Bookshop at prconline.com
Coronary Stenosis: Imaging, Structure and PhysiologyJavier Escaned and Patrick Serruys, editors