FL - Voeltz - 2012-06-14 - VOELTZ Reply to SOS Additional Brief
Iván Núñez Gil. Cardiología Intervencionista. HSCS. · The REPLACE-2 Trial (N=6,010):...
Transcript of Iván Núñez Gil. Cardiología Intervencionista. HSCS. · The REPLACE-2 Trial (N=6,010):...
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Iván Núñez Gil.
Cardiología Intervencionista. HSCS.
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Intervencionismo estructural.
Intervencionismo coronario.
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Congénitas. ◦ Cierre de CIA-FOP. ◦ Cierre CIV. ◦ Estenosis pulmonar. ◦ Coartación aorta. ◦ Realizar shunts.
Implante de prótesis transcatéter (TAVI) ◦ Aórtica ◦ Valve in valve (todas las posiciones).
Reparación mitral percutánea (mitraclip). Cierre de orejuela. Otras (ablación renal, CIV postinfarto, biopsias,
etc…).
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Acceso: ◦ Radial. ◦ Femoral. ◦ Otros: Braquial, bypasses.
Técnica: ◦ Diagnóstico. Angiografía. Imagen intracoronaria (IVUS, OCT..) Fisiología intracoronaria (guía de presión…)
◦ Terapéutico. Aspiración trombos. Angioplastia simple. Angioplastia e implante de stent (convencional, fármaco
activo o reabsorbible). Otros: Rotablación, braquiterapia, etc…
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Registro Español (1990-2010): REC 2011
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Registro Español (1990-2010): REC 2011
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Registro Español (1990-2010): REC 2011
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DIAGNÓSTICO
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ANGIOGRAFÍA.
OTRAS TÉCNICAS INVASIVAS
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-Guía de presión.
-Ecografía intracoronaria (IVUS).
-Tomografía de coherencia óptica (OCT).
-Histología virtual.
-Angioscopia.
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BASAL
HIPEREMIA CFR
FFR
IMR = Pd / (1 / Tmn) en hiperemia
GUÍA DE PRESIÓN PARÁMETROS DE MEDIDA DEL FLUJO CORONARIO
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MORFOLOGIA NORMAL
1. ADVENTICIA: elastina y colageno. Limitada internamente por LEE. Alta ecogenicidad.
2. MEDIA: Células músculo liso. Ecolucente. ↓ grosor con la edad.
3. INTIMA: Endotelio y conectivo subendotelial. Limitada por lateralmente por LEI. Capa ecodensa. ↑ grosor con la edad y aterosclerosis.
4. LUMEN.
5. HALO.
6. CATETER.
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MORFOLOGÍA NORMAL -Intima (4 μm): endotelio y capa colágena subendotelial.
-LEI (20 μm): capa fina de fibras elásticas hiperrefrigente.
-Media (125-350 μm): capa oscura, puede no visualizarse completamente en presencia de aterosclerosis y remodelado.
-LEE.
-Adventicia: no se visualiza el límite externo del vaso
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TRATAMIENTO
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Antitrombótico ◦ AAS
◦ Clopidogrel-Prasugrel…
◦ Heparina-Bivalirudina-enoxa-fondaparinux…
◦ Inh IIb-IIIa
Betabloqueante, IECAs, IBPs.
Control Ctes.
Seriación biomarcadores.
Vigilancia analítica.
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Sin elevación del ST ◦ Angina inestable.
◦ Infarto de miocardio (sin q)
Con elevación del ST
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Convencionales (metálicos, BMS)
Farmacoactivos o recubiertos (DES)
Reabsorbibles (en desarrollo).
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Nakagawa, 2011
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COMPLICACIONES
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The REPLACE-2 Trial (N=6,010):
Predictors of One-Year Mortality in PCI
Voeltz MD, Patel AD, Feit F, et al. Am J Cardiol, June 2007, in press.
Variable OR (95%CI) p-value
Age ≥ 75 2.28 (1.51, 3.46) 0.0001
Pre-procedural Anemia 2.12 (1.49, 3.13) 0.0002
BMI > 25 (vs. 20-25) 0.61 (0.40, 0.99) 0.007
Pre-procedure LVEF ≤ 50% 2.15 (1.44, 3.21) 0.0002
CHF 3.58 (2.27, 5.65) <.0001
Prior Angina 2.16 (1.25, 3.75) 0.006
Major Bleeding 2.66 (1.44, 4.92) 0.002
MI 2.46 (1.44, 4.20) 0.001
Revascularization 3.30 (1.36, 8.00) 0.008
Major Bleeding
REPLACE-2
• Intracranial, retroperitoneal • Observed bleed with fall in Hgb 3g/dL • No observed bleed with fall in Hgb 4g/dL • Transfusion 2 units PRBC or whole blood
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Complicaciones acceso.
Complicaciones procedimiento.
Patología subyacente – tratamiento completo.
Complicaciones patología.
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Complicaciones acceso.
Complicaciones procedimiento.
Patología subyacente – tratamiento completo.
Control estricto FRCV (DM?)
Doble antiagregación.
Betabloqueo.
IECAs-antialdosterónicos.
Estatinas
Complicaciones patología.
Nuevas PC (TC coronarias, nueva CNG…)
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