Faivre-service2 - C.N.C.H · Sténose >70% IVUS sonde 20mHz Lésion de bifurcation du TC...
Transcript of Faivre-service2 - C.N.C.H · Sténose >70% IVUS sonde 20mHz Lésion de bifurcation du TC...
CNCHG2009
CNCHG2009
CNCHG2009
CNCHG2009
CNCHG2009
CNCHG2009
Operator and Hospital Volume-Outcome Relationship in Patients Undergoing Elective Balloon Angioplasty. Jollis J et al. Circulation 1997;95:2485
Operator Volume Hospital Volume
Outcome from 97,478 Medicare patients treated in 1992
75 cases/year 200 cases/year
CNCHG2009
CNCHG2009
La cardiologie interventionnelle en CHG
• 70 salles de cardiologie interventionnelle (PCI).
• « 444 » Cardiologues interventionnels.
• 41 119 PCI en 2007.
92 ATC/opérateur/an
C e n t r e s H o s p i t a l i e r sN o m b r e d ' a n g i o p l a s t i e s
r é a l i s é e s e n 2 0 0 7
A v ig n o n 1 3 3 6
M e t z 1 2 0 0
L e n s 1 1 0 0
B o u rg e s 1 0 8 5
S t L a u r e n t d u V a r 1 0 0 0
L a g n y 9 7 5
P a u 9 6 7
L e P le s s is R o b in s o n - M a ri e L a n n e lo n g u e 9 5 0
L a R o c h e ll e 9 1 2
A n n e c y 9 0 0
C o lm a r ( P S P H ) 8 7 5
A n g o u le m e ( s t m i c h e l ) 8 4 9
M u lh o u s e 8 2 4
C h a rt r e s 8 0 0
V a l e n c ie n n e s 7 9 0
L y o n S t L u c S t J o s e p h ( P S P H ) 7 8 3
C o m p iè g n e 7 7 0
P e r p i g n a n 7 6 8
F r e j u s 7 6 3
O r le a n s 7 1 5
A ix e n P r o v e n c e 7 0 0
N e v e r s 6 9 9
N io r t 6 6 3
B e l f o r t 6 5 0
To u lo n 6 5 0
Va le n ce 6 0 0
Brive s la Ga illa rde 6 0 0 p rév u s c ar d é bu t aoû t 2 00 8
Va n n es 6 0 0
Ha g ue n e au 5 8 0
Pa ris Mon tso u ris 5 5 1
Mont fe rm e il 5 5 0
Lo rie nt 5 3 5
Au x e rre 5 1 2
Co rbe il E sson e 5 1 2
Ba y o nn e 5 0 0
La Ro ch e /Yon 5 0 0
Ne u illy /S e in e 5 0 0
Po n to ise 5 0 0
Sa in t-Qu e n tin 5 0 0
Pé rigu e u x 4 8 0
Vich y 4 6 4
St B rie uc 4 7 3
Ba s tia 4 5 9
St Den is la Ré u n io n 4 5 0
Le Ha vre 4 2 8
Ro u b aix 4 2 5
Le Ma ns 4 2 0
Villen e u ve S t G eo rg e s 4 2 0
Bo u lo gn e Billa nc o u rt 4 1 7
S t M a lo 4 1 2
D u n k e r q u e 4 1 1
V e rs a il le s ( A n d ré M ig n o t ) 4 0 8
L o m m e 4 0 2
E a u b o n n e 4 0 0
G re n o b l e C lin i q u e M u tu a lis t e (P S P H ) 4 0 0
Q u im p e r 4 0 0
R o d e z 4 0 0
M o n t re u i l 3 9 9
A rg e n te u il 3 8 3
P o is s y S t G e rm a in 3 8 0
L ib o u rn e 3 6 0
S u re s n e s (h ô p i ta l F o c h ) 3 5 0
C a n n e s 3 0 0 ( d é b u t a c t iv i té 2 0 0 7 )
T a rb e s 3 0 0
T ro y e s 2 6 0
A u ln a y s s b o is 2 5 9
G o n e s s e 2 5 8
C o lm a r (C H ) 2 5 0
A ja c c io 2 0 5
T ra c y -le -M o n t (o is e ) 2 0 0
P a p e e t e 1 8 0
M a n t e s la J o li e 1 2 0
L a v a l 1 0 0
N o u m é a ?
Le top Ten
Les « EnVoied’Extinction »
Le down Ten
CH A.MIGNOT
PARLY II
CH POISSY
Centre d’Evecquemont
Port Marly
Trappes
CH MANTES
La situation dans les Yvelines 27
Coronarographies AngioplastiesÉVECQUEMONT, 1 083 493 46%PORT MARLY - CMC de l'Europe 512 246 48%LE CHESNAY - Parly II 1 302 607 47%TRAPPES - CMC Ouest Parisien 461 233 51%POISSY, 810 444 55%VERSAILLES - André Mignot 946 360 38%MANTES LA JOLIE 290 90 31%
Registre Cardio ARHIFYvelines - Activité 2008
Sténose >70%
IVUS sonde 20mHz Lésion de bifurcation du TC
Aujourd’hui, samedi 28 novembre 2009, je suis seul et d’astreinte…..
Mardi 2 décembre, nous serons trois….
En salle, et pour l’astreinte, nous n’avons qu’une auxiliaire et…
que deux lits de SSPI….
Nos anesthésistes ne « veulent » pas venir nous épauler…
Et nous devons débuter le 24/24 en janvier 2010Avec l’appui logistique du SAMU 78 et 27
Mais pour combien de temps…..
Aujourd’hui, samedi 28 novembre 2009, je suis seul et d’astreinte…..
Mardi 2 décembre, nous serons trois….
En salle, et pour l’astreinte, nous n’avons qu’une auxiliaire et…
que deux lits de SSPI….
Nos anesthésistes ne « veulent » pas venir nous épauler…
Et nous devons débuter le 24/24 en janvier 2010Avec l’appui logistique du SAMU 78 et 27
Mais pour combien de temps…..
La VIE du Service de CARDIOLOGIE de Mantes
La VIE du Service de CARDIOLOGIE de Mantes
IVUS, outil indispensable pourcertaines procédures.
CNCHG2009
CNCHG2009
FAME 2 TCT 2009• reduced mortality and myocardial infarction at two years by 34%• reduced MI at two years by 37%
• cost-saving and does not prolong procedure time• decreased amount of contrast agent used
CNCHG2009
CNCHG2009
FAME 2 in TCT 2009• reduced mortality and myocardial infarction at two years by 34%• reduced MI at two years by 37%
• cost-saving and does not prolong procedure time• decreased amount of contrast agent used
•The routine measurement of FFR during PCI with DES in patients with MVD: •is superior to current angiography-guided treatment strategy, in reducing by ~30% the rate of the composite endpoint of death, MI, re-PCI and CABG, at 1 year. This strategy also reduces individual endpoints such as mortality and MI at 1 year. •is cost-saving, greatly reducing the number of stents used •does not prolong the procedure •reduces the number of stents used •decreases the amount of contrast agent used and results in a similar, if not better, functional status
•FAME trial supports the evolving paradigm of “Functionally Complete Revascularisation”, i.e. stenting of ischemic lesions and medical treatment of non-ischemic ones.. •FFR confirms to be a very helpful instrument for more accurate decision making during interventional procedures
CNCHG2009
CNCHG2009
The consensus of the SYNTAX in EuroPCR 2009 session was:
•CABG remains the gold standard of care for patients with three-vessel or LM coronary artery disease, since the use of CABG, as compared with PCI, resulted in lower rates of the combined endpoint of MACCE at 1 year. •Based on a non-significant difference in MACCE at 1 year, the SYNTAX results suggest that 66% of all patients with threevessel or LM coronary artery disease are still best treated with CABG. For the remaining 1/3 of such patients with a low SYNTAX Score (0-22), PCI may be considered as an alternative to surgery (with the exception of insulino-dependent diabetic patients). Again it should be remembered that this statement is based on 1 year data. Longer follow-up results will be presented during the ESC meeting. According to previous studies one can foresee further diverge of MACCE with longer follow-up. •A Heart Team Concept is mandatory for such patients with MVD or LM stenosis. In complex patients, the diagnostic procedure should be separate from the PCI, when eventually indicated. Time is needed in order to discuss management options, allowing for an informed decision.
CNCHG2009
CNCHG2009
CNCHG2009
CNCHG2009
CNCHG2009
CNCHG2009
Assistance mécanique pour le Choc cardiogénique
IABP Impella Tandem Heart
CNCHG2009
CNCHG2009
Hospital Volume-Outcome Relationship in Patients Undergoing Elective PTCA
Hannan E et al. JAMA 1997;19:892-8
Outcome from 62,670 Medicare patients treated between 1991-1994 in NY State
600 cases/year
1.12
0.80.85
0.79
0.95
0.5
0.75
1
1.25
<400
400-
599
600-
799
800-
999
>100
0
Statewide Mortality: 0.9%
CNCHG2009
CNCHG2009
Procedural Complexity and Operator Volume-Outcome Relationship in Patients Undergoing
Elective Balloon Angioplasty. Ellis S et al. Circulation 1997;95:2479
5.9
1.72.4
22.4
0
2
4
6
8
<70 70-99
100-142
143-270
>270
%
P<0.001
Low Risk Lesions(N=12,985 PCI Patients 1993-94)
P<0.001
High Risk Lesions(N=12,985 PCI Patients 1993-94)
8.4
5.8
7.8
4.9
2.7
0
2
4
6
8
<70 70-99
100-142
143-270
>270
%
Operator Volume per Year Operator Volume per Year
CNCHG2009
CNCHG2009
Operator and Hospital Volume-Outcome Relationship With the Use of Coronary Stents
McGrath P et al. JAMA 2000;284:3139-44
3.52 3.33 3.19
5.665.24
4.5
0
2
4
6
8
<30 30-60 >60
Death Death or CABG
%
P<0.001
Operator Volume per Year(N=167,208 PCI Patients in 1997)
4.88
3.86
3.11
6.88
5.94 5.87
0
2
4
6
8
<80 80-160 >160
Death Death or CABG
P<0.001
Hospital Volume per Year(N=167,208 PCI Patients in 1997)
%
CNCHG2009
CNCHG2009
Operator and Hospital Volume-Outcome Relationship With the Use of Coronary Stents
McGrath P et al. JAMA 2000;284:3139-44
6.13 6.05 5.96
6.06 5.715.17
5.1 4.9 4.6
0
2
4
6
8
<30 30-60 >60
>160
80-160
<80
%
Operator Volume per Year Hospit
al Volu
me
per Y
ear
CNCHG2009
CNCHG2009
Operator and Hospital Volume-Outcome Relationship With the Use of Coronary Stents
Kastrati A et al. JACC 1998;32:970-6
Overall Operator Volume Annual Operator Volume
Outcome of 3,409 PCI patients treated between 1992-1997
CNCHG2009
CNCHG2009
Volume-Outcome Relationship With the Use of Coronary Stents Stratified for Lesion Complexity
Kastrati A et al. JACC 1998;32:970-6
Outcome of 3,409 PCI patients treated between 1992-1997
CNCHG2009
CNCHG2009
Operator and Hospital Volume-Outcome Relationship in Contemporary PCI
Moscucci M et al. JACC 2005;46:625-32
2.041.66 1.51
1.11 1.42
7.38
6.13
4.974.15 4.15
0
2
4
6
8
1-33 34-89 90-139 140-206 207-582
Death MACE
%
P<0.001
18,504 PCI Patients treated in 2002
CNCHG2009
CNCHG2009
199 197189
170
0
50
100
150
200
5-11 12-20 21-33 >33
Hospital Volume and Mortality for Patients With Acute MI Undergoing PCI
Canto J et al. N Engl J Med 2000;342:1573
7.7 7.57
5.7
0
2
4
6
8
5-11 12-20 21-33 >33
%
P<0.01
In-Hospital Death(N=36,535 Primary PCI Patients)
P<0.001
Door-to-Ballon Times(N=36,535 Primary PCI Patients)
Min
utes
Hospital Volume per Year Hospital Volume per Year
CNCHG2009
CNCHG2009
Hospital Volume and Mortality for Patients With Acute MI Undergoing PCI
Magid DJ et al. JAMA 2000;284:3131
6.2
4.5
3.4
5.9 5.95.4
0
2
4
6
8
Low Intermediate High
Primary PCI Thrombolysis
P=0.58 P<0.001 P<0.001NRMI-Registry-62,299 patients with acute MI treated from 1994-1999
-446 acute care hospitalslow PCI volume:<16 cases/yearintermediate: 17-48 cases/yearhigh PCI volume: >49 cases/year
10,144 1,423 21,577 8,817 8605 11,733
%
CNCHG2009
CNCHG2009
Operator and Hospital Volume-Outcome Relationship in Primary PCI
Vakili B et al. Circulation 2001;104:2171-6
7.1
3.8
0
2
4
6
8
Low (1-10) High (>10)
In-h
ospi
talM
orta
lity
% RR=0.43(0.21-0.83)
P=0.01
Operator Volume Hospital Volume
5.8
4
0
2
4
6
8
Low (1-56) High (>56)
1,342 STEMI patients from New York State in 1995
In-h
ospi
talM
orta
lity
% RR=0.56(0.29-1.1)
P=0.11
CNCHG2009
CNCHG2009
3
4.2
5.7
7.4
0
2
4
6
8
<90 90-120 121-150
>150
In-h
ospi
tal M
orta
lity
(%)
Door-to-balloon Time(Minutes)
Door-to-Balloon Time And Mortality in Patients With AMI Undergoing PCI
McNamara R et al. JACC 2006;47:2180-6
NRMI 3-4 Registry (1999-2004) 29,222 primary PCI patients
CNCHG2009
CNCHG2009
Resténose clinique après PCI répétées avec DES