Sin título de diapositiva...bSS, rSS and variation of SYNTAX score after LM PCI Left Main Left Main...
Transcript of Sin título de diapositiva...bSS, rSS and variation of SYNTAX score after LM PCI Left Main Left Main...
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L A P A Z Daniel Berrocal, MD, PhD, FACC
Jefe de Cardiologia Intervencionista
Intervencionismo Coronario
de Alto Riesgo
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L A P A Z Daniel Berrocal, MD, PhD, FACC
Jefe de Cardiologia Intervencionista
NO TENGO CONFLICTO DE INTERESES
RESPECTO A ESTA PRESENTACIÓN
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CTO
Ca+
Tortuosidad extrema
Enfermedad difusa
Edad
FE%
EPOC
Como definimos riesgo?
Presentación
Clínica
Riesgo
de sangrado
COMPLEJIDAD
ANATÓMICA
(SYNTAX)
RIESGO CLÍNICO
(EuroScore-STS)
(TACTICS)
IR
Dbt
Comorb
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50
40
30
20
10
0
0 1 2 3 4 5
Cu
mu
lati
ve M
AC
E %
Follow Up Time (years)
2746 2452 2351 2178 2077 1880
2721 2485 2410 2235 2166 1952
# at Risk
Selective
Invasive
Routine
Invasive
Cumulative risk of CV death or MI by risk group
High
Intermediate
Low
Routine Invasive
Selective Invasive
Fox KAA on behalf of RITA-3, FRISC-II and ICTUS trialists. ACC/i2 Summit; March 14, 2010; Atlanta, GA
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0
5
10
15
20
25
Risk stratification by EKG, prior history of IHD and humoral
markers *p<0.01
Prognostic value of early cTnI and CRP in Chest Pain Unit
Death
&
MI
at
120 d
ays (
%)
EKG - & CAD History - EKG + or CAD History + EKG + & CAD History +
TOTAL cTn I + & CRP +
Adaptado de Dr. Jose L. Navarro Estrada
4.0%
19.3%
cTn I + or CRP +
* 17.7%
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0 5 10 15 20 25 30 0 1 2 3 4 5 6 7 8 9 10 11 12 Days from Randomization Months from Randomization
Mo
rta
lity%
Meta-analysis OASIS & CURE (N=34.146)
Major Bleeding
NO Major Bleeding 2.5%
12.8%
P<0.001
Eikelboom JW et al. Circulation 2006. 114:774-782
5X 4X
Ndrepepa G et al. JACC 2008. 51:690-697
Any Bleeding
NO Bleeding
14.1%
3.3%
P<0.001
Mo
rta
lity%
20
15
10
5
0
Pooled analysis ISAR-REACT, ISAR-SWEET,
ISAR-SMART-2, and ISAR-REACT-2 (N=5.384)
14
12
10
8
6
4
2
0
Bleeding and Mortality
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P=0.04
P=0.004
Chamié D et al. TCT 2010
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Capodanno D, et al. Catheter Cardiovasc Interv In press
P < 0.001 P < 0.001 P = 0.18
Baseline SYNTAX
score
Residual SYNTAX
score
D SYNTAX Score (bSS-rSS)
Calibration(χ2): 2.45
Discrimination (AUC): 0.73
Calibration(χ2): 0.60
Discrimination (AUC): 0.72
Calibration(χ2): 3.13
Discrimination (AUC): 0.55
DHIGH-LOW = 12% DHIGH-LOW = 17% DHIGH-LOW = 3%
Two-year cardiac mortality
bSS, rSS and variation of SYNTAX score after LM PCI
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Left Main
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Left Main
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Death
CSS vs. SYNTAX score.
Better discrimination in mortality, but limitations remain
SYNTAX score
MACE
P<0.001
P≤0.03
P<0.001
P≤0.03
c-statistic = 0.62
c-statistic = 0.61
c-statistic = 0.66
c-statistic = 0.58
11.7±7.3
CSS
17.4±20.5
Tertiles are not in the
anticipated order
Modest gain in
calibration vs
SYNTAX score (χ2 8
vs 6)
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Stroke
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# 347 J.S.
♂ 87 años
SIA con isquemia posterolateral
7 días de internación en UCI
EUROscore 24%
STS 13%
Syntax 29
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Bivalirudina
Rotablator DES a Tronco
DES a ostium de CX
3 DES a trifurcacion de CX
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PRE POST
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7 Meses después
SIA con cambios laterales
Trop I= 0.9
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Rotablator 3 DES a DA
(“full metal jacket”)
Bivalirudina
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PRE POST
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diameter stenosis (%)
FF
R
100 80 60 40 20 0
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
1066 Non-LM lesions
Mismatch Disease in the Cath Lab
AMC data
16% Reverse
mismatch
57%
Mismatch
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0.75 0.84
LAD, FFR LCX, FFR
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MLA 5.7mm2
Distal LM Rupture
LM from LAD pullback LM from LCX pullback
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Híbridos
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Resultados de 130 casos hibridosTECAB-PCI
• 2001 to 2009:
• 3 MIDCAB, AH-TECAB 96, BH-TECAB 31 pts
• Mortalidad Peri-op 0.7%
• F/U: 6% IAM, 0.7% ACV, 8% nueva PCI, 0 Muertes.
• 75% Libres de MACE
Bonatti,et al. 2011 EJCTS
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Robotic EndoACAB
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ROBOTIC LIMA HARVESTING
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Cumulative survival of 410 patients undergoing totally endoscopic coronary artery
bypass grafting from 2001 to 2010 at the University of Maryland and at Innsbruck
Medical University.
Bonatti J et al. Circulation 2011;124:236-244
Copyright © American Heart Association
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Hybrid coronary revascularization (defined as the
planned combination of LIMA-to-LAD artery grafting and
PCI of ≥1 non-LAD coronary arteries may be reasonable
as an alternative to multivessel PCI or CABG in an
attempt to improve the overall risk-benefit ratio of the
procedures.
Hybrid Coronary Revascularization
I IIa IIb III
ACC/AHA/SCA 2011
Guidelines
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♀ 38
Dolor precordial típico de mas de 30 minutos
Al llegar a la guardia de nuestro centro se
constata electrocardiograma normal
Enzimas cardiacas normales
Prueba ergométrica una semana anterior leve
dolor precordial opresivo que cedió solo
Ecocardiograma transtorácico que fue normal
I II III
aVF aVL aVR
V1 V2 V3
V4 V5 V6
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24 horas
ANGOR 5/10
ECG sin cambios
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4to día post ATC
angor típico
I II III
aVF aVL aVR
V1 V2 V3
V4 V5 V6
II
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CRM ATC
Decisión de revascularización
CTO
Ca+
Tortuosidad extrema
Enfermedad difusa
Edad
FE%
EPOC
IR
Hibridos Presentación
Clínica
Riesgo
de sangrado
COMPLEJIDAD
ANATÓMICA
(SYNTAX)
RIESGO CLÍNICO
(EuroScore-STS)
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L A P A Z Daniel Berrocal, MD, PhD, FACC
Jefe de Cardiologia Intervencionista
La estratificación clínica y anatómica
es muy importante
Debemos contar con gran disponibilidad
de dispositivos y drogas
Tener en cuenta los procedimientos en etapas (“staged”)